Cardiac stem cells and methods of identifying and using the same

ABSTRACT

Methods of isolating cardiac cells, including cardiac cells capable of regenerating cardiac tissue are provided. Compositions comprising cardiac cells, including cardiac cells capable of regenerating cardiac tissue are also provided. Methods of using cardiac cells, cardiac progenitor cells, including cardiac cells capable of regenerating cardiac tissue, are provided. Methods of identifying the prognosis of patients treated for heart disease and/or methods of predicting the regeneration of cardiac cells in a subject are also provided.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation of U.S. patent application Ser. No.14/648,621 entitled “Cardiac Stem Cells And Methods Of Identifying AndUsing The Same,” filed Jul. 24, 2017, which is 35 U.S.C. § 371 nationalphase application of International PCT Application No.PCT/US2013/072660, filed on Dec. 2, 2013, which claims the benefit ofand priority to U.S. Provisional Application 61/731,835, filed Nov. 30,2012, each of which is hereby incorporated by reference in its entirety.

GOVERNMENT INTERESTS

The embodiments disclosed herein were made with government support underP20 HL101443, awarded by US National Institutes of Health, therefore,the government may have certain rights.

BACKGROUND

Not Applicable

BRIEF SUMMARY OF THE INVENTION

This Summary is provided to present a summary of some of the embodimentsdescribed herein. This summary is submitted with the understanding thatit will not be used to interpret or limit the scope or meaning of theclaims.

Embodiments described herein are directed to marker compositionspredictive of cardiac regeneration following therapy. Methods ofmonitoring patient recovery, mitosis, drug discovery and the like arealso provided. In some embodiments, the methods utilize detection ofbiomarker expression, activity or function. Novel cell types and usesthereof, are also provided.

Disclosed herein are compositions and methods to isolate cardiacprogenitor cells, and methods to treat a subject for a heart disease.Some embodiments disclosed herein are methods of predicting regenerationof cardiac cells. In some embodiments, a method of predictingregeneration of cardiac cells in a subject treated for a heart diseasemay comprise obtaining a biological sample comprising cardiac cells fromthe subject; measuring phosphorylated retinoblastoma (pRb) levels in thebiological sample; and comparing the phosphorylated retinoblastoma (pRb)levels in the biological sample to a baseline control, wherein anincreased levels of pRb levels in the subject's biological sample whencompared to the baseline control is predictive of the regeneration ofthe cardiac cells in the subject.

Some embodiments disclosed herein are directed to identify prognosis ofa subject treated for heart disease. In some embodiments, a method ofidentifying a subject treated for heart disease as a subject with a goodprognosis may comprise obtaining a biological sample comprising cardiaccells from the subject; measuring phosphorylated retinoblastoma (pRb)levels in the biological sample; and comparing the phosphorylatedretinoblastoma (pRb) levels in the biological sample to a baselinecontrol, wherein an increased level of pRb in the subject's biologicalsample when compared to the baseline control identifies that subject ashaving a good prognosis. In some embodiments, the subject may be treatedwith adult bone marrow-derived mesenchymal cells (MSCs), adult cardiacstem cells (CSCs), or any combination thereof.

Some embodiments are directed to identifying candidate agents thatmodulate Rb pathway. In some embodiments, a method of identifying acandidate agent to modulate Rb pathway in a cardiac progenitor cell maycomprise contacting the candidate agent with a population of cardiacprogenitor cells (CPCs); and comparing phosphorylated Rb levels in thepopulation of cardiac progenitor cells contacted with the candidateagent to phosphorylated Rb levels in a population of CPCs not contactedwith the candidate agent, wherein a difference in the phosphorylated Rblevels identifies the candidate agent as an agent that modulates the Rbpathway in the cardiac progenitor cell. In some embodiments, the cardiacprogenitor cells (CPCs) are positive for phosphorylated Rb^(ser608)(pRb^(ser608)), Gata4, or any combination thereof. In some embodiments,the difference in the phosphorylated Rb levels is at least 10%.

In some embodiments, a method of regenerating cardiac cells in vitro orin vivo may comprise contacting the cardiac cells with at least oneagent that inhibits the function of retinoblastoma (Rb), alternatereading frame of Ink4a (ARF) protein, or any combination thereof. Thecardiac cells may be cardiac stem cells (CSCs), cardiac progenitor cells(CPCs), cardiomyocytes, or any combination thereof. In some embodiments,the agent may be a siRNA inhibitor, a shRNA inhibitor, an antisensenucleotide inhibitor, a peptide mimetic inhibitor, a small molecule, anantibody, a kinase that phosphorylates Rb, a transcriptional repressorof ARF, or any combination thereof. In some embodiments, the agent mayincrease the phosphorylation of Rb in cardiac cells, and/or decrease theexpression of ARF in cardiac cells.

In other embodiments, a method of treating an ischemic disorder in asubject in need thereof may comprise administering a therapeuticallyeffective amount of an agent that inhibits the function ofretinoblastoma (Rb) and/or alternate reading frame of Ink4a (ARF) incardiac cells. The ischemic disorder may be caused by heart surgery,organ transplantation, angioplasty, stenting, or any combinationthereof. In some embodiments, the agent may increase the phosphorylationof Rb in cardiac cells, decrease the expression of ARF in cardiac cells,or any combination thereof.

In a further embodiment, a progenitor cell may be formed by the processof co-culturing mesenchymal stem cells (MSCs) and cardiac stem cells(CSCs) in vitro or in vivo, wherein the progenitor cell comprises aphenotype identified by markers positive for phosphorylatedretinoblastoma serine 608 (pRb^(ser608)), and Gata4 (Gata4⁺). In someembodiments, the progenitor cell may be ARF negative. In otherembodiments, the progenitor cell may be a cardiac progenitor cell (CPC).

Disclosed herein are methods to identify cardiac precursor cells. Insome embodiments, a method of isolating cardiac progenitor cells from apopulation of cardiac cells may comprise identifying the cardiacprogenitor cells in the population as cells comprising phosphorylatedretinoblastoma protein; and isolating the identified cardiac progenitorcells. In some embodiments, the cardiac progenitor cells are identifiedby contacting the population of cardiac cells with an agent that detectsphosphorylated Rb. In some embodiments, the agent that detects thephosphorylated Rb may be an antibody. In some embodiments, the methodmay further comprise administering the isolated cardiac progenitor cellsin a therapeutically effective amount to a subject in need of suchadministration. In some embodiments, the subject may be a subject with aheart disease.

In some embodiments, a method of isolating cardiac progenitor cells froma population of cardiac cells may comprise identifying the cardiacprogenitor cells in the population as cells that are positive for atleast one marker selected from phospho-Rb^(pos), Gata4^(pos), ARF^(neg)and any combination thereof; and isolating the identified cardiacprogenitor cells. In some embodiments, the isolated cardiac progenitorcells may have the following markers: N-cadherin^(pos),connexin-43^(pos), Isl1^(pos), Wt1^(pos), CDK2^(pos), CDK4^(pos),CDK6^(pos), E2F^(pos), phospho-p107^(pos), phospho-p130^(pos),CCNAP^(pos), CCND1^(pos), CCND2^(pos), CCND3^(pos)CCNE^(pos),c-kit^(pos), CD3^(neg), CD14^(neg), CD68^(neg), Nkx2.5^(pos),MITF^(pos), MEF2c^(pos), and any combination thereof. In an additionalembodiment, a composition may comprise an isolated population of cardiacprogenitor cells obtained according to the methods described herein.

In some embodiments, a method of isolating regenerative cardiomyocytesfrom a population of mature cardiomyocytes may comprise identifying theregenerative cardiomyocytes in the population as cells that are positivefor at least one marker selected from phospho-Rb^(pos), Gata4^(pos),ARF^(neg), N-cadherin^(pos), connexin-43^(pos), Isl1^(pos), Wt1^(pos),CDK2^(pos), CDK4^(pos), CDK6^(pos), E2F^(pos), phospho-p107^(pos),phospho-p130^(pos), CCNA^(pos), CCND1^(pos), CCND2^(pos), CCND3^(pos),CCNE^(pos), CDKN1a^(neg), CDKN1b^(neg), CDKN1c^(neg), CDKN2a^(neg),CDKN2b^(neg), CDKN2^(neg), CDKN3^(neg), CD3^(neg), CD14^(neg),CD68^(neg), Nkx2.5^(neg), MITF^(pos), MEF2c^(pos), and any combinationthereof; and isolating the identified regenerative cardiomyocytes.

DESCRIPTION OF DRAWINGS

FIG. 1 shows the interactions between hMSCs/hCSCs induce endogenousregenerative activity via pRb^(Ser608) in host cardiomyocytes andcardiac progenitors. (FIGS. 1A, 1B), Confocal immunofluorescenceanalysis reveals that expression of pRb^(Ser608) (red nuclei) occurs incardiomyocytes (yellow arrowheads) and Gata4⁺ progenitors (arrows). ApRb^(Ser608) cardiomyocyte exhibiting cytokinesis (yellow arrowhead withasterisk) and a very small, possibly newly formed, pRb^(Ser608+)cardiomyocyte are delineated in (FIG. 1A). Cells not committed tocardiac lineage (white arrowheads) do not express pRb^(Ser608).Tropomyosin (green, FIG. 1A) and Gata4 (white, FIG. 1B) were employed asmarkers to identify cardiomyocytes and/or cardiac progenitors,respectively. FIGS. 1C, 1D: The hCSCs-treated hearts have significantlyhigher concentrations of pRb^(Ser608+)/Gata4⁺ progenitors compared totherapy with hMSCs or placebo, both in the infarct (FIG. 1C) and borderzones (FIG. 1D). However, combination of hCSCs with hMSCs furtherenhanced this effect. FIGS. 1E, 1F: In addition to the expansion of thepRb^(Ser608+) progenitor cell pool, animals treated with combination ofcells, exhibited a significantly higher fraction of pRb^(Ser608+) adultcardiomyocytes, both in the infarct (FIG. 1E) and border (FIG. 1F) zonescompared to the other groups. N=3 animals/group; values are shown asmeans±SEM; *p≤0.0001. CPCs, Gata4⁺ progenitors; CM, cardiomyocytes; hpf,high-power field.

FIG. 2 shows that the induction of pRb^(Ser608+) in host CPCs does notrelate to cell-cycling activity. FIGS. 2A, 2B: Confocalimmunofluorescence against the mitotic marker HP3⁺ demonstratessubstantial numbers of Gata4⁺ progenitors in mitosis in the infarct(FIG. 2A) and border zones of the porcine hearts. FIGS. 2C, 2D: Althoughstem cell treated hearts are invested with significantly higher numbersof pRb^(Ser608+)/Gata4⁺ progenitors, the numbers of HP3⁺/Gata4⁺progenitors in mitosis are not significantly different between groups,neither in the infarct (FIG. 2C), nor in border zones. Thus, inductionof pRb^(Ser608) following hCSCs/hMSCs interactions, is more likely toregulate cell-fate rather than cell-cycle decisions in Gata4⁺ heartprogenitors.

FIG. 3 shows that pRb^(Ser608) and ARF repression in host cardiomyocytesby hMSC/hCSCs link to full cell cycle re-entry. FIGS. 3A-3E: amitotically dividing adult porcine cardiomyocyte in the infarct zone ofhuman stem cell-treated hearts, as illustrated by expression of HP3.Laminin (red, FIG. 3C) highlights the cardiomyocyte borders with theextracellular matrix. In the merged image (FIG. 3D), the borders ofhealthy myocardium with the dead, scarred tissue are demarcated with awhite line. Higher magnification of the mitotic cardiomyocyte (FIG. 3D,arrowhead) in FIG. 3E, illustrates cytokinesis, by the laminin+ borders(white lines). FIGS. 3F, 3G: the pools of mitotic cardiomyocytes in theinfarct (FIG. 3F) and border (FIG. 3G) zones are dramatically expandedfollowing hMSC/hCSC transplantation compared to the other groups. FIGS.3H, 3I: A mitotically dividing cardiomyocyte (inset) in a hMSC/hCSCtreated heart expressing HP3 (white, FIG. 3H) and pRb^(Ser608) (red,FIG. 3I). Importantly, the dividing cell lacks expression of ARF (greennuclei), indicating the potential for undergoing additional rounds incell cycle. This phenotype is consistent with the existence of an adult,transiently amplifying, regenerative cardiomyocytic population, withbroader proliferative potentials than regular cardiomyocytes. Whitearrowheads depict pRb^(Ser608)-negative cardiomyocytes expressing ARF intheir nucleus. FIG. 3J, 3K: Compared to other groups, animals treatedwith the combination of hCSCs and hMSCs exhibit significantly higherrates in pRb^(Ser608+)/ARF⁽⁻⁾ cardiomyocytes, evidencing a novelmechanism of adult cardiomyocyte replication. CM, cardiomyocyte; hpf,high-power field.

FIG. 4 shows that pRb^(Ser608)-regulated cardiomyocyte replication andprogenitor cell commitment links to myocardial scar size reduction.Linear regression analyses of the cMRI-calculated percentage changes inscar size with: FIGS. 4A, 4B: the number of pRb^(Ser608+)/Gata4⁺progenitors in the infarct and border zones; the number of pRb^(Ser608+)progenitors within the infarct (FIG. 4A), but not the border (FIG. 4B),zone correlates significantly with the reduction in scar size. FIGS. 4C,4D: the % of pRb^(Ser608+) cardiomyocytes in the infarct and borderzones; no correlation between scar size reduction and the % ofpRb^(Ser608+) cardiomyocytes was observed, in infarct (FIG. 4C) orborder (FIG. 4D) zone. However, the % of pRb^(Ser608+)/ARF⁽⁻⁾cardiomyocytes in the infarct (FIG. 4E) and border (FIG. 4F) zonescorrelated significantly with the extent of myocardial scar shrinkage.Thus, pRb^(Ser608+) followed by ARF repression is essential for fullregenerative activity in cardiomyocytes.

FIG. 5 is a schematic representation of a summary of the study. FIG. 5Ashows that therapeutic transplantation of a combination of humanmesenchymal and cardiac stem cells results in durable engraftment ofhuman stem cells in ischemic porcine epicardium and perivascular sites.FIG. 5B shows that the xenografted stem cell mixture, in contrast toeach cell type alone, induces endogenous regenerative activity via pRbphosphorylation at ser-608. FIG. 5C shows that this post-translationalmodification is propagated exclusively in cardiac lineage-specific cellsand exhibits a dual effect. In conjunction with ARF repression, itrestores full cell-cycling activity in host cardiomyocytes, whereas atthe same time, activates regenerative Gata4⁺ host progenitors. As aresult, significant restoration of dead cardiac muscle occurs.

FIG. 6 shows the expression patterns of pRb^(Ser608) in the healthyporcine heart. Confocal immunofluorescence analyses reveals thatepicardial (FIG. 6A) and endocardial (FIG. 6C) cells, but not cells ofthe compact myocardial wall (FIG. 6B), exhibit pRb^(Ser608) in thehealthy porcine heart. Arrowheads indicate Gata4⁺/pRb^(Ser608+)progenitors; arrows indicate pRb^(Ser608+) cardiomyocytes.

FIG. 7 shows that regenerative cardiomyocytes are significantly smallerthan regular cardiomyocytes. FIG. 7A: Morphometric analyses of thecross-sectional area of HP3⁺, mitotically dividing, cardiomyocytes inthe hearts of human stem cell treated animals (blue bar) and non-mitoticcardiomyocytes in the placebo-treated group (black bar), reveals thatthe former are significantly smaller in size. FIGS. 7B, 7C:representative photomicrographs of an HP3⁺ cardiomyocyte (FIG. 7B,inset) and non-dividing cardiomyocytes (FIG. 7C). Cardiac myosin lightchain (cMLC2v, red) and Gata4 were used as cardiomyocyte markers.

FIG. 8 shows that pRb^(Ser608+)/ARF⁽⁻⁾ cardiomyocytes correlate withmitotic activity. Linear regression analyses of the numbers of HP3+,mitotically dividing cardiomyocytes with the % of pRb^(Ser608+)cardiomyocytes (FIG. 8A, and pRb^(Ser608+)/ARF⁽⁻⁾ cardiomyocytes (FIG.8B), reveals that the levels of pRb^(Ser608) accurately predict therates of cardiomyocyte mitosis. Regression is more robust whenpRb^(Ser608) is accompanied by an ARF-negative phenotype (FIG. 8B).

FIG. 9 shows that the induction of pRb^(Ser608+)/ARF⁽⁻⁾ regenerativephenotype in cardiomyocytes requires both MSCs and CSCs. Representativeconfocal photomicrographs of porcine hearts treated with placebo (FIGS.9A, 9B), hMSCs+hCSCs (FIGS. 9C, 9D), hCSCs. (FIGS. 9E, 9F) or hMSCs(FIGS. 9G, 9H), and immunostained for pRb^(Ser608+) (red nuclei), ARF(white nuclei) and Tropomyosin (green). Notice the dramatic differencein pRb^(Ser608+) cardiomyocytes following hMSCs+hCSCs treatment (FIGS.9C, 9D), compared to the other groups. In addition, the vast majority ofcardiomyocyte nuclei express the tumor suppressor ARF, resulting in cellcycle arrest. However, following transplantation of both hMSCs and hCSCs(FIGS. 9C, 9D), ARF expression becomes repressed in a significantfraction of host cardiac myocytes (inset and arrows in FIG. 9B).

FIG. 10 shows that the majority of mitotically dividing cardiomyocytesexpress ARF. Confocal immunofluorescence depicts an HP3⁺ (white),mitotically dividing cardiomyocyte (arrow), that co-expresses ARF(green) and pRb^(Ser608) (red). Expression of ARF restrictscardiomyocytes from undergoing additional cell cycles.

FIG. 11 shows relative gene expression analysis in humaninduced-pluripotentstem cells (hiPSCs) during cardiomyocytedifferentiation. Values are normalized to embyroid bodies (EB) on day 0.

FIG. 12 demonstrates the knock-down of Rb in human embryonic stem cells(hESCs). FIGS. 12A and B show expression of GFP in hESCs indox-untreated and dox-treated cells, respectively, as measured byfluorescent microscopy.

FIG. 13 demonstrate the knock-down of Rb in embyroid bodies. FIG. 13Ashows the quantification of beating embyroid bodies (EB) on day 8 andday 10. FIG. 13B shows the fluorescent microscopy of GFP⁺ cells inembyroid bodies at day 10. FIG. 13C shows the expression of Rb inembyroid bodies on day 10.

FIG. 14 shows gene expression analysis of Gata4, Isl1, and TnnI in day10 EBs expressing control and Rb shRNA, according to an embodiment.

FIG. 15 demonstrates gene expression analysis of cell cycle activatorsin day 8-10 EBs expressing control and Rb shRNA, according to anembodiment.

FIG. 16 shows gene expression analysis of cell cycle inhibitors in day10 EBs expressing control and Rb shRNA, according to an embodiment.

DETAILED DESCRIPTION

Embodiments may be practiced without the theoretical aspects presented.Moreover, the theoretical aspects are presented with the understandingthat the embodiments are not bound by any theory presented.

All genes, gene names, and gene products disclosed herein are intendedto correspond to homologs from any species for which the compositionsand methods disclosed herein are applicable. Thus, the terms include,but are not limited to genes and gene products from humans and mice. Itis understood that when a gene or gene product from a particular speciesis disclosed, this disclosure is intended to be exemplary only, and isnot to be interpreted as a limitation unless the context in which itappears clearly indicates. Thus, for example, for the proteins or genesdisclosed herein, which in some embodiments relate to mammalian nucleicacid and amino acid sequences are intended to encompass homologousand/or orthologous genes and gene products from other animals including,but not limited to other mammals, fish, amphibians, reptiles, and birds.In some embodiments, the genes or nucleic acid sequences are human.

Unless otherwise defined, all terms (including technical and scientificterms) used herein have the same meaning as commonly understood by oneof ordinary skill in the art. It will be further understood that terms,such as those defined in commonly used dictionaries, should beinterpreted as having a meaning that is consistent with their meaning inthe context of the relevant art and will not be interpreted in anidealized or overly formal sense unless expressly so defined herein.

The terminology used herein is for the purpose of describing particularembodiments only and is not intended to be limiting. As used herein, thesingular forms “a”, “an” and “the” are intended to include the pluralforms as well, unless the context clearly indicates otherwise.Furthermore, to the extent that the terms “including”, “includes”,“having”, “has”, “with”, or variants thereof are used in either thedetailed description and/or the claims, such terms are intended to beinclusive in a manner similar to the term “comprising.”

The term “about” or “approximately” means within an acceptable errorrange for the particular value as determined by one of ordinary skill inthe art, which will depend in part on how the value is measured ordetermined, i.e., the limitations of the measurement system. Forexample, “about” can mean within 1 or more than 1 standard deviation,per the practice in the art. Alternatively, “about” can mean a range of±10% of the referenced value.

“Administering” when used in conjunction with a therapeutic, means toadminister a therapeutic directly into or onto a target tissue or toadminister a therapeutic to a patient whereby the therapeutic positivelyimpacts the tissue to which it is targeted. “Administering” acomposition may be accomplished by oral administration, injection,infusion, parenteral, intravenous, mucosal, sublingual, intramuscular,subcutaneous absorption or by any method in combination with other knowntechniques. The therapeutic can also be implanted or placed at the siteof treatment.

The term “animal,” “patient,” or “subject” as used herein includes, butis not limited to, humans and non-human vertebrates such as wild,domestic and farm animals. In some embodiments, the term refers tohumans.

As used herein, the term “autologous” is meant to refer to any materialderived from the same individual to whom it is later to be re-introducedinto the individual.

The term “allogeneic cell” refers to a cell that is of the same animalspecies but genetically different in one or more genetic loci as theanimal that becomes the “recipient host.” This usually applies to cellstransplanted from one animal to another non-identical animal of the samespecies. However, in some embodiments, cells from one species may beadministered to a different species.

“Biological samples” include solid and body fluid samples. Thebiological samples used herein can include cells, protein or membraneextracts of cells, blood or biological fluids such as ascites fluid orbrain fluid (e.g., cerebrospinal fluid). Examples of solid biologicalsamples include, but are not limited to, samples taken from tissues ofthe central nervous system, bone, breast, kidney, cervix, endometrium,head/neck, gallbladder, parotid gland, prostate, pituitary gland,muscle, esophagus, stomach, small intestine, colon, liver, spleen,pancreas, thyroid, heart, lung, bladder, adipose, lymph node, uterus,ovary, adrenal gland, testes, tonsils and thymus. Examples of “bodyfluid samples” include, but are not limited to blood, serum, semen,prostate fluid, seminal fluid, urine, saliva, sputum, mucus, bonemarrow, lymph, and tears. A biological sample can also include cardiaccells, cardiac progenitor cells, cardiac regenerative cells, or maturecardiomyocytes.

“Bone marrow derived progenitor cell” (BMDC) or “bone marrow derivedstem cell” refers to a primitive stem cell with the machinery forself-renewal constitutively active. Included in this definition are stemcells that are totipotent, pluripotent and precursors. A “precursorcell” can be any cell in a cell differentiation pathway that is capableof differentiating into a more mature cell. As such, the term “precursorcell population” refers to a group of cells capable of developing into amore mature cell. A precursor cell population can comprise cells thatare totipotent, cells that are pluripotent and cells that are stem celllineage restricted (i.e. cells capable of developing into less than allhematopoietic lineages, or into, for example, only cells of erythroidlineage).

“Diagnostic” or “diagnosed” means identifying the presence or nature ofa pathologic condition. Diagnostic methods differ in their sensitivityand specificity. The “sensitivity” of a diagnostic assay is thepercentage of diseased individuals who test positive (percent of “truepositives”). Diseased individuals not detected by the assay are “falsenegatives.” Subjects who are not diseased and who test negative in theassay, are termed “true negatives.” The “specificity” of a diagnosticassay is 1 minus the false positive rate, where the “false positive”rate is defined as the proportion of those without the disease who testpositive. While a particular diagnostic method may not provide adefinitive diagnosis of a condition, it suffices if the method providesa positive indication that aids in diagnosis.

As used herein, “heart disease” refers to any type of heart diseaseincluding cardiovascular disease, myocardial stunning, peripheralvascular disease, cardiomyopathy, hypertrophic cardiomyopathy, dilatedcardiomyopathy, atherosclerosis, coronary artery disease, ischemic heartdisease, myocarditis, viral infection, wounds, hypertensive heartdisease, valvular disease, congenital heart disease, myocardialinfarction, congestive heart failure, arrhythmias, diseases resulting inremodeling of the heart, etc. Diseases of the heart can be due to anyreason, such as for example, damage to cardiac tissue such as a loss ofcontractility (e.g., as might be demonstrated by a decreased ejectionfraction). Heart disease may also result from intermittent claudication,tachycardia, ischemia-reperfusion, acute renal failure, stroke,hypotension, embolism, thromboembolism (blood clot), sickle celldisease, localized pressure to extremities to the body, tumors, and thelike.

“Ischemia” refers to a lack of oxygen flow to the heart which results inmyocardial ischemic damage. As used herein, the phrase myocardialischemic damage includes damage caused by reduced blood flow to themyocardium. Non-limiting examples of causes of myocardial ischemia andmyocardial ischemic damage include: decreased aortic diastolic pressure,increased intraventricular pressure and myocardial contraction, coronaryartery stenosis (e.g., coronary ligation, fixed coronary stenosis, acuteplaque change (e.g., rupture, hemorrhage), coronary artery thrombosis,vasoconstriction), aortic valve stenosis and regurgitation, andincreased right atrial pressure. Ischemia may also be caused by heartsurgery, organ transplantation, angioplasty, stenting, or anycombination thereof. Non-limiting examples of adverse effects ofmyocardial ischemia and myocardial ischemic damage include: myocytedamage (e.g., myocyte cell loss, myocyte hypertrophy, myocyte cellularhyperplasia), angina (e.g., stable angina, variant angina, unstableangina, sudden cardiac death), myocardial infarction, and congestiveheart failure. Damage due to myocardial ischemia may be acute orchronic, and consequences may include scar formation, cardiacremodeling, cardiac hypertrophy, wall thinning, dilatation, andassociated functional changes. ischemia may also be caused due to heartdiseases described herein. The existence and etiology of acute orchronic myocardial damage and/or myocardial ischemia may be diagnosedusing any of a variety of methods and techniques well known in the artincluding, e.g., non-invasive imaging (e.g., MRI, echocardiography),angiography, stress testing, assays for cardiac-specific proteins suchas cardiac troponin, and clinical symptoms. These methods and techniquesas well as other appropriate techniques may be used to determine whichsubjects are suitable candidates for the treatment methods describedherein.

By the term “modulate,” it is meant that any of the mentioned activitiesdescribed herein, are, e.g., increased, enhanced, increased, agonized(acts as an agonist), or promoted. Modulation can increase activity morethan 1-fold, 2-fold, 3-fold, 5-fold, 10-fold, 100-fold, etc., overbaseline values. Modulation can also decrease its activity belowbaseline values. Modulation can also normalize an activity to a baselinevalue.

The terms “patient” or “individual” are used interchangeably herein, andrefers to a mammalian subject to be treated. In some embodiments, thepatient is a human. In some cases, the methods can be used inexperimental animals, in veterinary application, and in the developmentof animal models for disease, including, but not limited to, rodentsincluding mice, rats, and hamsters; and primates. In some embodiments,the patient is a patient in need thereof.

As used herein, the phrase “in need thereof” means that the patient hasbeen identified as having a need for the particular method or treatment.In some embodiments, the identification can be by any means ofdiagnosis. In any of the methods and treatments described herein, theanimal or mammal can be in need thereof. In some embodiments, the animalor mammal is in an environment or will be traveling to an environment inwhich a particular disease, disorder, or condition is prevalent.

The term “syngeneic cell” refers to a cell which is of the same animalspecies and has the same genetic composition for most genotypic andphenotypic markers as the animal who becomes the recipient host of thatcell line in a transplantation or vaccination procedure. This usuallyapplies to cells transplanted from identical twins or may be applied tocells transplanted between highly inbred animals.

“Stem cell niche” refers to the microenvironment in which stem cells arefound, which interacts with stem cells to regulate stem cell fate. (See,for example, Kendall Powell, Nature 435, 268-270 (2005). The word‘niche’ can be in reference to the in vivo or in vitro stem cellmicroenvironment. During embryonic development, various niche factorsact on embryonic stem cells to alter gene expression, and induce theirproliferation or differentiation for the development of the fetus.Within the human body, stem cell niches maintain adult stem cells in aquiescent state, but after tissue injury, the surroundingmicroenvironment actively signals to stem cells to either promote selfrenewal or differentiation to form new tissues. Several factors areimportant to regulate stem cell characteristics within the niche:cell-cell interactions between stem cells, as well as interactionsbetween stem cells and neighboring differentiated cells, interactionsbetween stem cells and adhesion molecules, extracellular matrixcomponents, the oxygen tension, growth factors, cytokines, andphysiochemical nature of the environment including the pH, ionicstrength (e.g. Ca2+concentration, metabolites like ATP are alsoimportant. The stem cells and niche may induce each other duringdevelopment and reciprocally signal to maintain each other duringadulthood. The niche also refers to specific anatomic locations thatregulate how they participate in tissue generation, maintenance andrepair. The niche saves stem cells from depletion, while protecting thehost from over-exuberant stem-cell proliferation. It constitutes a basicunit of tissue physiology, integrating signals that mediate the balancedresponse of stem cells to the needs of organisms. Yet the niche may alsoinduce pathologies by imposing aberrant function on stem cells or othertargets. The interplay between stem cells and their niche creates thedynamic system necessary for sustaining tissues, and for the ultimatedesign of stem-cell therapies.

“Treatment” is an intervention performed with the intention ofpreventing the development or altering the pathology or symptoms of adisorder. Accordingly, “treatment” can refer to therapeutic treatment orprophylactic or preventative measures. In some embodiments, thetreatment is for therapeutic treatment. In some embodiments, thetreatment is for prophylactic or preventative treatment. Those in needof treatment can include those already with the disorder as well asthose in which the disorder is to be prevented. As used herein,“ameliorated” or “treatment” refers to a symptom which is approaches anormalized value (for example a value obtained in a healthy patient orindividual), e.g., is less than 50% different from a normalized value,is less than about 25% different from a normalized value, is less than10% different from a normalized value, or is not significantly differentfrom a normalized value as determined using routine statistical tests.

Generally speaking, the term “tissue” refers to any aggregation ofsimilarly specialized cells which are united in the performance of aparticular function.

As used herein, the term “therapeutic” means an agent utilized todiscourage, combat, ameliorate, prevent or improve an unwantedcondition, disease or symptom of a patient.

A “therapeutically effective amount” or “effective amount” of an agentor a cell is a predetermined amount calculated to achieve the desiredeffect, i.e., to ameliorate, prevent or improve an unwanted condition,disease or symptom of a patient. The activity contemplated by thepresent methods includes both therapeutic and/or prophylactic treatment,as appropriate. The specific dose of the cells/agents administeredaccording to the methods described herein to obtain therapeutic and/orprophylactic effects will, of course, be determined by the particularcircumstances surrounding the case, including, for example, thecells/agents administered, the route of administration, and thecondition being treated. The effective amount administered may bedetermined by a physician in the light of the relevant circumstancesincluding the condition to be treated, the choice of cells/agents to beadministered, and the chosen route of administration. A therapeuticallyeffective amount of the cell/agent is typically an amount such that whenit is administered in a physiologically tolerable excipient composition,it is sufficient to achieve an effective systemic concentration or localconcentration in the target tissue. The cells can also be administeredwithout excipients.

As used herein, the term “stem cell” refers to a cell from the embryo,fetus, or adult that has, under certain conditions, the ability toreproduce itself for long periods or, in the case of adult stem cells,throughout the life of the organism. It also can give rise tospecialized cells that make up the tissues and organs of the body.

As used herein, the term, “pluripotent stem cell” refers to a cell thathas the ability to give rise to types of cells that develop from thethree germ layers (mesoderm, endoderm, and ectoderm) from which all thecells of the body arise. The only known sources of human pluripotentstem cells are those isolated and cultured from early human embryos andfrom fetal tissue that was destined to be part of the gonads.

As used herein the term, “embryonic stem cell” refers to a cell that isderived from a group of cells called the inner cell mass, which is partof the early (4- to 5-day) embryo called the blastocyst. Once removedfrom the blastocyst the cells of the inner cell mass can be culturedinto embryonic stem cells. These embryonic stem cells are not themselvesembryos.

Cells are referred to herein as being positive or negative for certainmarkers. For example, a cell can be positive for GATA, which can also bereferred to as GATA^(pos). The superscript notation “pos” refers to acell that is positive for the marker linked to the superscript. Incontrast a marker with the superscript “neg” refers to a cell that isnegative for that marker. For example, a cell that is referenced as“AR^(neg)” is negative for ARF. A “+” can also be used to reference thatthe marker as positive. A “−” can also be used to reference the markeras negative.

As used herein, the term “adult stem cell” refers to a cell that is anundifferentiated (unspecialized) cell that occurs in a differentiated(specialized) tissue, renews itself, and becomes specialized to yieldall of the specialized cell types of the tissue in which it is placedwhen transferred to the appropriate tissue. Adult stem cells are capableof making identical copies of themselves for the lifetime of theorganism. This property is referred to as “self-renewal.” Adult stemcells usually divide to generate progenitor or precursor cells, whichthen differentiate or develop into “mature” cell types that havecharacteristic shapes and specialized functions, e.g., muscle cellcontraction or nerve cell signaling. Sources of adult stem cells includebone marrow, blood, the cornea and the retina of the eye, brain,skeletal muscle, dental pulp, liver, skin, the lining of thegastrointestinal tract and pancreas.

As used herein, the term “totipotent cell” refers to a cell capable ofdeveloping into all lineages of cells. Similarly, the term “totipotentpopulation of cells” refers to a composition of cells capable ofdeveloping into all lineages of cells. Also as used herein, the term“pluripotent cell” refers to a cell capable of developing into a variety(albeit not all) lineages and are at least able to develop into allhematopoietic lineages (e.g., lymphoid, erythroid, and thrombocyticlineages). Bone marrow derived stem cells contain two well-characterizedtypes of stem cells. Mesenchymal stem cells (MSC) normally formchondrocytes and osteoblasts. Hematopoietic stem cells (HSC) are ofmesodermal origin that normally give rise to cells of the blood andimmune system (e.g., erythroid, granulocyte/macrophage, megakaryocyteand lymphoid lineages). In addition, hematopoietic stem cells also havebeen shown to have the potential to differentiate into the cells of theliver (including hepatocytes, bile duct cells), lung, kidney (e.g.,renal tubular epithelial cells and renal parenchyma), gastrointestinaltract, skeletal muscle fibers, astrocytes of the CNS, Purkinje neurons,cardiac muscle (e.g., cardiomyocytes), endothelium and skin.

The term “xenogeneic cell” refers to a cell that derives from adifferent animal species than the animal species that becomes therecipient animal host in a transplantation or vaccination procedure.

Some embodiments disclosed herein are directed to markers predictive ofcardiac regeneration in response to treatments, which can include theadministration of cardiac cells. Prior to the embodiments describedherein it was not known whether a patient's heart cells would regenerateafter treatment because the mechanistic underpinnings of endogenouscellular replication in the adult mammalian heart were heretoforeunknown.

Retinoblastoma protein (Rb), the tumor suppressor product of theretinoblastoma susceptibility gene, is a 110 kDa protein which plays animportant role in regulating cell growth and differentiation. Central tothe role of the Rb protein as a tumor suppressor is the ability of Rb tosuppress inappropriate proliferation by arresting cells in the G1 phaseof the cell cycle. Rb protein exerts its growth suppressive function bybinding to transcription factors including E2F-1, PU.1, ATF-2, UBF,Elf-1, and c-Abl. The binding of Rb protein is governed by itsphosphorylation state. Hypo- or under-phosphorylated forms of Rb bindand sequester transcription factors, most notably those of the E2F/DPfamily, inhibiting the transcription of genes required to traverse theG1 to S phase boundary of the cell cycle. This cell cycle inhibitoryfunction is abrogated when Rb undergoes phosphorylation catalyzed byspecific complexes of cyclins and cyclin-dependent protein kinases(cdks). In addition, Rb is also phosphorylated by non-cdks, such as MAPkinase, p38 kinase, JNK1, atypical protein kinase C, apoptotic signals,and the like. Thus, phosphorylation of Rb results in inhibition of itsfunction.

The INK4a/ARF gene locus has been shown to encode two unrelated proteinsfrom alternative but partially overlapping reading frames: (i)p16^(Ink4a) and (ii) ARF (p14^(ARF) humans and p19^(ARF) the mouse). ARFstabilizes p53 by interfering with an auto-regulatory loop involving p53and Double Minute 2 (Hdm2 in humans, Mdm2 in mice) that maintains p53expression under normal cellular conditions. Mdm2 is known to bind p53and inhibit the transactivation function of p53. Further, Mdm2 shuttlesp53 from the nucleus to the cytoplasm and facilitates p53 degradation.In addition, Mdm2 also acts as an E3 ubiquitin ligase toward p53 withinthe ubiquitin-dependent 26S proteasome pathway. Therefore, Mdm2 inhibitsp53 activity in the nucleus through multiple and diverse mechanisms.ARF, in-turn, inhibits Mdm2 activity and restores p53 levels andfunction. Loss of ARF results in decrease in p53 levels/function leadingto cell cycle progression.

Stem cells from the bone marrow are the most-studied type of adult stemcells. They can be used clinically to restore various blood and immunecomponents to the bone marrow via transplantation. There are currentlyidentified two major types of stem cells found in bone marrow:hematopoietic stem cells (HSC, or CD34⁺ cells) which are typicallyconsidered to form blood and immune cells, and stromal (mesenchymal)stem cells (MSC) that are typically considered to form bone, cartilage,muscle and fat. However, both types of marrow-derived stem cellsrecently have demonstrated extensive plasticity and multipotency intheir ability to form the same tissues.

A “progenitor or precursor” cell occurs in fetal or adult tissues and ispartially specialized; it divides and gives rise to differentiatedcells. Researchers often distinguish precursor/progenitor cells fromadult stem cells in that when a stem cell divides; one of the two newcells is often a stem cell capable of replicating itself again. Incontrast when a progenitor/precursor cell divides, it can form moreprogenitor/precursor cells or it can form two specialized cells.Progenitor/precursor cells can replace cells that are damaged or dead,thus maintaining the integrity and functions of a tissue such as liveror brain.

Mesenchymal stem cells are the formative pluripotential blast cellsfound inter alia in bone marrow, blood, dermis and periosteum that arecapable of differentiating into any of the specific types of mesenchymalor connective tissues (i.e. the tissues of the body that support thespecialized elements; particularly adipose, osseous, cartilaginous,elastic, and fibrous connective tissues) depending upon variousinfluences from bioactive factors, such as cytokines.

Certain methods of isolating and/or purifying mesenchymal stem cellshave been described. In some embodiments, mesenchymal stem cells areisolated from bone marrow of adult patients. In some embodiments, thecells are passed through a density gradient to eliminate undesired celltypes. The cells can be plated and cultured in appropriate media. Insome embodiments, the cells are cultured for at least one day or aboutthree to about seven days, and removing non-adherent cells. The adherentcells can then be plated and expanded.

Other methods for isolating and culturing stem cells useful are alsoknown. Umbilical cord blood is an abundant source of hematopoietic stemcells. The stem cells obtained from umbilical cord blood and thoseobtained from bone marrow or peripheral blood appear to be very similarfor transplantation use. Placenta is an excellent readily availablesource for mesenchymal stem cells. Moreover, mesenchymal stem cells canbe derivable from adipose tissue and bone marrow stromal cells andspeculated to be present in other tissues. While there are dramaticqualitative and quantitative differences in the organs from which adultstem cells can be derived, the initial differences between the cells maybe relatively superficial and balanced by the similar range ofplasticity they exhibit.

Homogeneous human mesenchymal stem cell compositions are provided whichserve as the progenitors for all mesenchymal cell lineages. MSCs areidentified by specific cell surface markers which are identified withunique monoclonal antibodies. The homogeneous MSC compositions areobtained by positive selection of adherent marrow or periosteal cellswhich are free of markers associated with either hematopoietic cell ordifferentiated mesenchymal cells. These isolated mesenchymal cellpopulations display epitopic characteristics associated with onlymesenchymal stem cells, have the ability to regenerate in culturewithout differentiating, and have the ability to differentiate intospecific mesenchymal lineages when either induced in vitro or placed invivo at the site of damaged tissue.

In order to obtain subject human mesenchymal stem cells, pluripotentmesenchymal stem cells are separated from other cells in the bone marrowor other MSC source. Bone marrow cells may be obtained from iliac crest,femora, tibiae, spine, rib or other medullary spaces. Other sources ofhuman mesenchymal stem cells include embryonic yolk sac, placenta,umbilical cord, fetal and adolescent skin, and blood.

In some embodiments, the mesenchymal stem cells are derived from one orsources comprising: autologous, heterologous, syngeneic, allogeneic orxenogeneic sources. These sources can include cell lines. As usedherein, “source” refers to the animal in which these stem cells wereobtained from, including human.

Differentiation of mesenchymal stem cells to the cardiac lineage iscontrolled by factors present in the cardiac environment. Localchemical, electrical and mechanical environmental influences alterpluripotent MSCs and convert the cells administered to the heart intothe cardiac lineage.

In some embodiments, cardiac stem cells are identified by markerscomprising: c-kit^(pos), CD3^(neg), CD14^(neg) and CD68^(neg). In someother embodiments, the cells are identified by the presence or absenceof markers as described herein.

Disclosed herein are methods to identify and isolate cardiac progenitorcells. Without wishing to be bound by theory, phosphorylated Rb (pRb)activity governs the endogenous cell proliferative and fate commitmentin the host response to cell therapy. The embodiments described hereinshow that the interactions between mesenchymal stem cells (MSCs) andcardiac stem cells (CSCs), rendered the host myocardium permissive forpRb and alternate reading frame of Ink4a (ARF) to regulate heartregeneration. Furthermore, identified were replicating myocytes,differentiating progenitors, and a pool of transient amplifyingprecursors as the endogenous regenerative cell sources. These mechanismsrecapitulate key features of the adult mammalian stem cell niche and,therefore, support a role for stem cell niches in the mammalian heart'sregenerative repertoire.

A novel cell type was generated and identified. Some embodiments areprovided in the examples section which follows. In some embodiments, anovel cell comprises properties identified as a transiently amplifying,regenerative cardiomyocytic cell, with broader proliferative potentialsthan regular cardiomyocytes. Additionally, morphometric analysisillustrated that the cross-sectional areas of these newly formedcardiomyocytes were significantly smaller compared to cardiomyocytes inthe placebo treated group (p<0.05), providing evidence that they aretransient amplifying progeny of host CPCs (see, e.g., FIG. 7). Theabundance of pRb^(Ser608) correlated significantly with the numbers ofcardiomyocytes in mitosis (FIG. 8A), further supporting the conclusionthat hMSCs/hCSCs interactions induce pRb^(Ser608) inactivation and thesubsequent regulation of cardiomyocyte cell-cycle activity. In someembodiments, an isolated cell comprises markers: HP3⁺, pRb^(Ser608+) andGata4⁺. In some embodiments, the isolated cell is ARF-negative. In someembodiments, the cell is a mammalian cell.

In some embodiments, a method of isolating regenerative cardiomyocytesfrom a population of cardiomyocytes may comprise identifying theregenerative cardiomyocytes in the population as cells that are positivefor at least one marker selected from phospho-Rb^(pos), Gata4^(pos),ARF^(neg), N-cadherin^(pos), connexin-43^(pos), Isl1^(pos), Wt1^(pos),CDK2^(pos), CDK4^(pos), CDK6^(pos), E2F^(pos), phospho-p107^(pos),phospho-p130^(pos), CCNA^(pos), CCND1^(pos), CCND2^(pos), CCND3^(pos),CCNE^(pos), CDKN1a^(neg), CDKN1b^(neg), CDKN1c^(neg), CDKN2a^(neg),CDKN2b^(neg), CDKN2c^(neg), CDKN3^(neg), c-kit^(pos), CD3^(neg),CD14^(neg), CD68^(neg), Nkx2.5^(pos), MITF^(pos), MEF2c^(pos), and anycombination thereof; and isolating the identified regenerativecardiomyocytes. In some embodiments, the population of cardiomyocytescontains mature cardiomyocytes.

In some embodiments, the cardiomyocytes that are phospho-Rb^(pos) areidentified as regenerative cardiomyocytes. In some embodiments, thecardiomyocytes that are phospho-Rb^(pos) and Gata4^(pos) are identifiedas regenerative cardiomyocytes. In some embodiments, the cardiomyocytesthat are phospho-Rb^(pos) and ARF^(neg) are identified as regenerativecardiomyocytes. In some embodiments, the cardiomyocytes that arephospho-Rb^(pos), Gata4^(pos), and ARF^(neg) are identified asregenerative cardiomyocytes. In some embodiments in addition to thepresence or markers referenced above, the cardiomyocytes that have atleast one, at least two, at least three, at least four, or at least fiveadditional markers selected from the group consisting ofN-cadherin^(pos), connexin-43^(pos), Isl1^(pos), Wt1^(pos), CDK2^(pos),CDK4^(pos), CDK6^(pos), E2F^(pos), phospho-p107^(pos),phospho-p130^(pos), CCNA^(pos), CCND1^(pos), CCND2^(pos), CCND3^(pos),CCNE^(pos), CDKN1a^(neg), CDKN1b^(neg), CDKN1c^(neg), CDKN2a^(neg),CDKN2b^(neg), CDKN2^(neg), CDKN3^(neg), c-kit^(pos), CD3^(neg),CD14^(neg), CD68^(neg), Nkx2.5^(pos), MITF^(pos), MEF2c^(pos) areidentified as regenerative cardiomyocytes. In some embodiments, thecardiomyocytes having all the markers are identified as regenerativecardiomyocytes.

In some embodiments, isolating the identified regenerativecardiomyocytes may be performed by any known technique in the art, suchas, but not limited to, fluorescence assisted cell sorter (FACS), laserscanning cytometry, fluorescent microscopy, RT-PCR, DNA hybridization,fluorescence in situ hybridization, mass spectroscopy, microarray,immunohistochemistry, or any combination thereof. The methods ofisolation are not critical and any method can be used so long as theisolation utilizes the presence or absence of markers described herein.

Also disclosed herein are methods to generate regenerating cells. Insome embodiments, a method of generating a regenerative cell comprisesco-culturing of mesenchymal stem cells (MSCs), cardiac stem cells (CSCs)or combinations of MSCs and CSCs in vitro, or administering to a subjectin need of treatment: mesenchymal stem cells (MSCs), cardiac stem cells(CSCs) or combinations of MSCs and CSCs. In some embodiments, theregenerative cell comprises a phenotype identified by markersHP3⁺/pRb^(Ser608+)/Gata4⁺//ARF-negative. In some embodiments, theregenerative cell comprises a phenotype identified by markerspRb^(Ser608+), Gata4⁺, and ARF⁻. In some embodiments, a progenitor cellmay be formed by the process of co-culturing mesenchymal stem cells(MSCs) and cardiac stem cells (CSCs) in vitro or in vivo, wherein theprogenitor cell comprises a phenotype identified by markers positive forphosphorylated retinoblastoma serine 608 (pRb^(Ser608)) and/or Gata4(Gata4⁺). The progenitor cell may be a cardiac progenitor cell (CPC). Insome embodiments, the progenitor cell may be ARF negative.

Gata-4 can be used as a cardiomyocyte marker. GATA transcription factorincludes members of the GATA family of zinc finger transcriptionfactors. GATA transcription factors are involved in the development ofseveral mesodermally derived cell lineages. GATA transcription factorsinclude GATA-4 and/or GATA-6. The GATA-6 and GATA-4 proteins sharehigh-level amino acid sequence identity over a proline-rich region atthe amino terminus of the protein that is not conserved in other GATAfamily members.

Detection of expression of additional cardiomyocyte specific proteinscan be achieved by using antibodies to, for example, myosin heavy chainmonoclonal antibody MF 20 (MF20), sarcoplasmic reticulum calcium ATPase(SERCA1) (mnAb 10D1) or gap junctions using antibodies to connexin 43.Other markers for cardiomyocytes comprise cardiac troponin I (cTnI),cardiac troponin T (cTnT), sarcomeric myosin heavy chain (MHC), GATA-4,Nkx2.5, N-cadherin, β1-adrenoceptor β1-AR), ANF, the MEF-2 family oftranscription factors, creatine kinase MB (CK-MB), myoglobin, or atrialnatriuretic factor (ANF). Antibodies can also be used to detect any orall of the markers described herein.

Also disclosed herein are methods to isolate regenerating progenitorcells. In some embodiments, a method of isolating cardiac progenitorcells from a population of cardiac cells may comprise identifying thecardiac progenitor cells in the population as cells comprisingphosphorylated retinoblastoma protein; and isolating the identifiedcardiac progenitor cells. In some embodiments, the cardiac progenitorcells are identified by contacting the population of cardiac cells withan agent that detects phosphorylated Rb. In some embodiments, the agentmay detect hyperphosphorylated Rb. In some embodiments, the agent maydetect any of the 16 putative phosphorylated serine or threonineresidues, including Ser-249, Thr-252, Thr-373, Thr-356, Ser-608,Ser-780, Ser-795, Ser-807, Ser-811, Thr-821, and Thr-826. In someembodiments, Rb is phosphorylated at Ser-608. In some embodiments, theagent that detects phosphorylated Rb may be an antibody. Antibodiesagainst phosphorylated Rb are known in the art and any such antibody maybe used. For example, an antibody that binds to Rb at phosphorylated Ser608 may be used.

In some embodiments, the isolated cardiac progenitor cells that areidentified because of phosphorylated retinoblastoma protein are alsopositive for Gata4 (Gata4⁺). In some embodiments, the isolated cardiacprogenitor cells that are identified because of phosphorylatedretinoblastoma protein are also are negative for ARF (ARF). In someembodiments, the isolated cardiac progenitor cells that are identifiedbecause of phosphorylated retinoblastoma protein are also positive forGata4 (Gata4⁺) and negative for ARF (ARF).

In some embodiments, the agent or the antibody described herein mayfurther comprise a detectable label, such as a chromophore, afluorophore, a chemiluminescent compound, an enzyme, a metal ion, andany combination thereof. In some embodiments, a secondary antibody thatspecifically recognizes the primary anti-pRb antibody may be used. Thesecondary antibody may be conjugated to detectable labels, such asperoxidases (example, horseradish or soybean peroxidase), alkalinephosphatase, β-galactosidase, chelated lanthanides, biotin, radiolabels,chromophores, fluorophores, and the like. The term “labeled”, withregard to the probe or antibody, can also encompass direct-labeling ofthe probe or antibody by coupling, i.e., physically linking, adetectable substance to the probe or antibody, as well asindirect-labeling of the probe or antibody by reactivity with anotherreagent that is directly-labeled. Examples of indirect labeling includedetection of a primary antibody using a fluorescently-labeled secondaryantibody and end-labeling of a DNA probe with biotin such that it can bedetected with fluorescently-labeled streptavidin.

Once the cardiac progenitor cells expressing phosphorylated Rb areidentified, the identified cells may be sorted from the remainingpopulation of cells. Non-limiting examples of sorting techniques thatmay be used are fluorescence assisted cell sorter (FACS), fluorescentplate reader, laser scanning cytometer, fluorescent microscope, or anycombination thereof. The isolated cardiac progenitor cells may bepositive for Gata4 (Gata4⁺) and/or negative for ARF (ARF).

In some embodiments, the isolated cardiac progenitor cells describedherein may be administered to a subject in need of such administration.For example, the subject may have a heart disease, a heart disorder,such as ischemia. Without wishing to be bound by theory, theadministered cardiac progenitor cells may differentiate into maturecardiomyoctes at the site of injury, and help in healing cardiac tissue.Examples of heart disease include, but are not limited to cardiovasculardisease, cardiomyopathy, myocardial stunning, peripheral vasculardisease, intermittent claudication, tachycardia, ischemia-reperfusion,myocardial infarction, acute renal failure, stroke, hypotension,embolism, thromboembolism (blood clot), sickle cell disease, localizedpressure to extremities to the body, tumors, and any combinationthereof.

In some embodiments, a method of isolating cardiac progenitor cells froma population of cardiac cells may comprise identifying the cardiacprogenitor cells in the population as cells that are positive for atleast one marker selected from phospho-Rb^(pos), Gata4^(pos), ARF^(neg),and any combination thereof; and isolating the identified cardiacprogenitor cells. In some embodiments, the cells that are positive forphospho-Rb^(pos) and Gata4 are identified as cardiac progenitor cells.In some embodiments, the cells that are positive for phospho-Rb^(pos)and negative for ARF are identified as cardiac progenitor cells. In someembodiments, the cells that are positive for Gata4 and negative for ARFare identified as cardiac progenitor cells. In some embodiments, thecells that are positive for at phospho-Rb^(pos) and Gata4, and negativefor ARF are identified as cardiac progenitor cells. In some embodiments,the identified cardiac progenitor cells are N-cadherin^(pos),connexin-43^(pos), Isl1^(pos), Wt1^(pos), CDK2^(pos), CDK4^(pos),CDK6^(pos), E2F^(pos), phospho-p107^(pos), phospho-p130^(pos),CCNA^(pos), CCND1^(pos), CCND2^(pos), CCND3^(pos), CCNE^(pos),c-kit^(pos), CD3^(neg), CD14^(neg), CD68^(neg), Nkx2.5^(pos),MITF^(pos), MEF2c^(pos), or any combination thereof.

In some embodiments, the isolated cardiac progenitor cells may also havethe following markers: N-cadherin^(pos), connexin-43^(pos), Isl1^(pos),Wt1^(pos), CDK2^(pos), CDK4^(pos), CDK6^(pos), E2F^(pos),phospho-p107^(pos), phospho-p130^(pos), CCNA^(pos), CCND1^(pos),CCND2^(pos), CCND3^(pos), CCNE^(pos), c-kit^(pos), CD3^(neg),CD14^(neg), CD68^(neg), Nkx2.5^(pos), MITF^(pos), MEF2c^(pos), or anycombination thereof. The negative expression of the marker implies thatthe level of expression of the protein or the mRNA in the progenitorcells is relatively low or absent when compared to non-progenitor cellsThe markers described herein may identified by any techniques known inthe art, such as but not limited to, fluorescence assisted cell sorter(FACS), laser scanning cytometry, fluorescent microscopy, RT-PCR, DNAhybridization, fluorescence in situ hybridization, mass spectroscopy,microarray, immunohistochemistry, and any combination thereof. The cellscan also be isolated by any known method, including, but not limited to,cell sorting.

In some embodiments, the method further comprises identifying cells thatare N-cadherin^(pos), connexin-43^(pos), Isl1^(pos), Wt1^(pos),CDK2^(pos), CDK4^(pos), CDK6^(pos), E2F^(pos), phospho-p107^(pos),phospho-p130^(pos), CCNA^(pos), CCND1^(pos), CCND2^(pos), CCND3^(pos),CCNE^(pos), c-kit^(pos), CD3^(neg), CD14^(neg), CD68^(neg),Nkx2.5^(pos), MITF^(pos), MEF2c^(pos), or any combination thereof priorto isolating the identified cardiac progenitor cells.

In an additional embodiment, a composition may comprise an isolatedpopulation of cardiac progenitor cells obtained according to the methodsdescribed herein.

In some embodiments, a method of isolating cardiac progenitor cells froma population of cardiac cells may comprise introducing into the cardiaccells a nucleic acid sequence encoding for a reporter protein and aninhibitor of Rb; screening the cells expressing the reporter protein;and isolating the cells expressing the reporter protein, whereinisolated cells contain decreased levels of Rb protein when compared tocells not expressing the reporter protein. In some embodiments, thereporter protein and the inhibitor may be encoded by different DNAmolecules. In some embodiments, the reporter protein and the inhibitormay be encoded by a single DNA molecule. The nucleic acid that isintroduced into the cardiac cells may be a plasmid, a vector, or a DNAfragment. In some embodiments, the vector may be a plasmid, cosmid,virus, bacteriophage, or any another vector that is conventionally usedin genetic engineering.

In some embodiments, the reporter protein may be green fluorescentprotein (GFP), enhanced green fluorescent protein (EGFP), enhancedyellow fluorescent protein (EYFP), blue fluorescent protein (BFP),enhanced blue florescent protein (EBFP), or enhanced cyan fluorescentprotein (ECFP). Additionally, the presence of reporter protein in thenuclei acid sequence has the advantage of tracking cells that expressthe inhibitor.

In some embodiments, the Rb inhibitor may be RNA interference (RNAi)molecules, such as small interfering RNA (siRNA), small hairpin RNA(shRNA), microRNA (miRNA), hybrid of miRNA, and shRNA, and antisenseRNA. The structure and function of short hairpin RNA molecules arewell-known to a skilled person. Short hairpin RNA is capable ofmediating gene knockdown in a process termed RNA interference. Once ashRNA molecule is transcribed in the cell, it is cleaved by an RNaseIII-like enzyme (Dicer) into double stranded small interfering RNAs(siRNA), and loses its loop structure. In an ATP dependent step, thesiRNAs become integrated into a multi-subunit protein complex, commonlyknown as the RNAi induced silencing complex (RISC), which guides thesiRNAs to the target RNA sequence. At some point during the integrationphase, the siRNA duplex unwinds, and the antisense strand remains boundto RISC and directs degradation of the complementary mRNA sequence by acombination of endo- and exo-nucleases.

The nuclei acid sequence may be introduced into the cardiac cells by anytechnique known in the art, such as transfection, viral transduction,electroporation, and the like. In some embodiments, the nuclei acidsequence may be part of a lentivirus construct, retrovirus construct,adenovirus construct, or any other plasmid constructs routinely used inthe art. In some embodiments, conditional vectors may be used that allowfor regulated expression of shRNA molecules and thus expression can beturned on leading to knockdown of the target gene in a tissue-specificand/or time dependent manner. Regulation can be achieved by using aninducing compound such as, for example, doxycycline or tetracyclinewhich acts on artificial regulatory sequences in the polymerase IIIpromoter.

Once the cardiac progenitor cells expressing the reporter protein areidentified, the identified cells may be sorted from the population ofcells. Non-limiting examples of sorting techniques that may be used arefluorescence assisted cell sorter (FACS), fluorescent plate reader,laser scanning cytometer, fluorescent microscope, or any combinationthereof. The isolated cells may be further confirmed by assays to detectthe expression levels of Rb protein. Such assays may be Westernblotting, RT-PCR, ELISA, immunohistochemistry, and the like. Further,the isolated cardiac progenitor cells may also be positive for Gata4(Gata4⁺), and negative for ARF (ARF).

Disclosed herein are also methods to treat a subject having a heartdisease. Heart disease (cardiac damage or disorder) characterized byinsufficient cardiac function includes any impairment or absence of anormal cardiac function or presence of an abnormal cardiac function.Abnormal cardiac function can be the result of disease, injury, and/oraging. As used herein, abnormal cardiac function includes morphologicaland/or functional abnormality of a cardiomyocyte, a population ofcardiomyocytes, or the heart itself. Non-limiting examples ofmorphological and functional abnormalities include physicaldeterioration and/or death of cardiomyocytes, abnormal growth patternsof cardiomyocytes, abnormalities in the physical connection betweencardiomyocytes, under- or over-production of a substance or substancesby cardiomyocytes, failure of cardiomyocytes to produce a substance orsubstances which they normally produce, and transmission of electricalimpulses in abnormal patterns or at abnormal times. Abnormalities at amore gross level include dyskinesis, reduced ejection fraction, changesas observed by echocardiography (e.g., dilatation), changes in EKG,changes in exercise tolerance, reduced capillary perfusion, and changesas observed by angiography. Abnormal cardiac function is seen with manydisorders including, for example, ischemic heart disease, e.g., anginapectoris, myocardial infarction, chronic ischemic heart disease,hypertensive heart disease, pulmonary heart disease (cor pulmonale),valvular heart disease, e.g., rheumatic fever, mitral valve prolapse,calcification of mitral annulus, carcinoid heart disease, infectiveendocarditis, congenital heart disease, myocardial disease, e.g.,myocarditis, dilated cardiomyopathy, hypertensive cardiomyopathy,cardiac disorders which result in congestive heart failure, and tumorsof the heart, e.g., primary sarcomas and secondary tumors. Heart damagealso includes wounds, such as for example, knife wound; biological (e.g.viral; autoimmune diseases) or chemical (e.g. chemotherapy, drugs);surgery; transplantation and the like.

In some embodiments, a method of treating a heart disease in a subjectin need thereof may comprise administering a therapeutically effectiveamount of cardiac progenitor cells that are disclosed herein. Thesubject may suffer from the heart disease due to a cardiovasculardisease, cardiomyopathy, myocardial stunning, peripheral vasculardisease, intermittent claudication, tachycardia, ischemia-reperfusion,myocardial infarction, acute renal failure, stroke, hypotension,embolism, thromboembolism (blood clot), sickle cell disease, localizedpressure to extremities to the body, tumors, and combinations thereof.Heart disease may also be due to morphological and functionalabnormalities of the heart, insufficient cardiac function, and heartdamage as described herein. The administered cardiac progenitor cellsmay have a phenotype expressing markers, such as Gata4 (Gata4⁺), andnegative for ARF (ARF). In addition, the cardiac progenitor cells maylack Rb function due to phosphorylation of Rb or may lack Rb expression.

Disclosed herein are methods to treat a subject having ischemia. Tissuesdeprived of blood and oxygen undergo ischemic necrosis or infarctionwith possible irreversible organ damage. Once the flow of blood andoxygen is restored to the organ or tissue (reperfusion), the organ doesnot immediately return to the normal preischemic state. Reperfusion ofthe blood flow is necessary to resuscitate the ischemic or hypoxictissue or organ. Timely reperfusion facilitates salvage of cells anddecreases morbidity and mortality. However, reperfusion of an ischemicarea may result in a paradoxical dysfunction including markedendothelial cell dysfunction, which results in vasoconstriction, andacute immune response due to platelet and leukocyte activation,increased oxidant production, and increased fluid and proteinextravasation.

In some embodiments, a method of treating an ischemic disorder in asubject in need thereof may comprise administering a therapeuticallyeffective amount of an agent that inhibits the function ofretinoblastoma (Rb) and/or alternate reading frame of Ink4a (ARF) incardiac cells. In some embodiments, the ischemic disorder may be causedby heart surgery, organ transplantation, angioplasty, stenting, or anycombination thereof. In addition, the ischemic disorder may also be dueto cardiovascular disease, cardiomyopathy, myocardial stunning,peripheral vascular disease, intermittent claudication, tachycardia,ischemia-reperfusion, myocardial infarction, acute renal failure,stroke, hypotension, embolism, thromboembolism (blood clot), sickle celldisease, localized pressure to extremities to the body, tumors, and anycombination thereof.

The agents that may be used to treat ischemic disorder may be agentsthat inhibit Rb function and/or ARF function. Such inhibition wouldresult in cell-cycle progression and proliferation of cardiomyocytesand/or cardiac progenitor cells, resulting in healing of the injuredtissue. Non-limiting of agents that may be used are RNAi molecules thatinhibit Rb and/or ARF expression, such as siRNA inhibitor, a shRNAinhibitor, or an antisense nucleotide inhibitor. In some embodiments,agents may also be a peptide mimetic inhibitor, a small molecule, anantibody, a kinase that phosphorylates Rb, a transcriptional repressorof ARF, or any combination thereof.

In some embodiments, the agent may also increase the phosphorylation ofRb in cardiac cells. For example, RNAi molecules that target cdkinhibitors (cip/kip family and INK4 family) may increase phosphorylationof Rb, and inhibit Rb function. In some embodiments, the agentsdescribed herein may also decrease the expression of ARF in cardiaccells. In addition, agents may also include transcriptional repressorsof ARF, transcriptional activators of Mdm2, or agents that increase thelevels of Mdm2 expression, decrease expression levels of p53, orincrease the degradation of p53. Furthermore, the agent may also be anactivator of cdk 4, an activator of cdk 6, an activator of E2F, anactivator of atypical protein kinase C, an activator of Skp2, anactivator of mdm2, an activator of MAP kinase, or any combinationthereof. One skilled in the art would understand that agents thatinhibit Rb pathway and/or ARF pathway may result in increased cellproliferation cardiac progenitor cells and help to heal ischemic injury.

The present disclosure provides methods for regenerating cardiac cellsin vitro or in vivo. In some embodiments, the method includes contactingthe cardiac cells with at least one agent that inhibits the function ofretinoblastoma (Rb), alternate reading frame of Ink4a (ARF) protein, orany combination thereof. The cardiac cells comprise cardiac stem cells(CSCs), cardiac progenitor cells (CPCs), cardiomyocytes, or anycombination thereof. In some embodiments, the agent may be any agentdescribed herein that inhibit the function of Rb. In some embodiments,the agent may be any agent described herein that inhibit the function ofARF. Non-limiting examples of agents include a siRNA inhibitor, a shRNAinhibitor, an antisense nucleotide inhibitor, a peptide mimeticinhibitor, a small molecule, an antibody, a kinase that phosphorylatesRb, a transcriptional repressor of ARF, or any combination thereof. Inaddition, agents may also include transcriptional repressors of ARF,transcriptional activators of Mdm2, or agents that increase the levelsof Mdm2 expression, decrease expression levels of p53, or increase thedegradation of p53. Furthermore, the agent may also be an activator ofcdk 4, an activator of cdk 6, an activator of E2F, an activator ofatypical protein kinase C, an activator of Skp2, an activator of mdm2,an activator of MAP kinase, or any combination thereof. Further, theagent described herein may increase the phosphorylation of Rb in cardiaccells, and/or decrease the expression of ARF in cardiac cells.

In another embodiment, a method of regenerating cardiac cells in vitroor in vivo, comprises contacting a biological sample in vitro oradministering to a patient suffering from a cardiac disease or disorder,a pharmaceutical composition wherein the composition comprises one ormore agents which inhibit the expression, function or activity ofretinoblastoma (Rb) and alternate reading frame of Ink4a (ARF). In someembodiments, mesenchymal stem cells (MSCs), cardiac stem cells (CSCs) orcombinations of MSCs and CSCs are optionally administered to a subjector are co-cultured in a sample in vitro. In some embodiments, thegenerated cell comprise a phenotype identified having markers:HP3⁺/pRb^(ser608+)/Gata4⁺//ARF-negative.

In some embodiments, methods are provided for predicting regeneration ofcardiac cells in a subject treated for a heart disease. In someembodiments, the method may comprise obtaining a biological samplecomprising cardiac cells from the subject; measuring phosphorylatedretinoblastoma (pRb) levels in the biological sample; and comparing thephosphorylated retinoblastoma (pRb) levels in the biological sample to abaseline control, wherein an increased levels of pRb levels in thesubject's biological sample when compared to the baseline control ispredictive of the regeneration of the cardiac cells in the subject. Insome embodiments, the measuring may comprise measuring and quantifyingphosphorylation at Ser-608 of the retinoblastoma protein. Thephosphorylated retinoblastoma (pRb) levels may be quantified by anyknown techniques in the art, such as immunohistochemical assays, Westernblot assays, ELISA, biochemical enzymatic assays, or any combinationthereof. In some embodiments, the cardiac cell may be a maturecardiomyocyte and/or a Gata4 positive (Gata4⁺) cardiac progenitor cell(CPC). Detection of an increased amount, expression or activity ofpRb^(ser608) is predictive of the regeneration of the cardiac cells in asubject. In embodiments, the pRb^(ser608) is detected in compactventricular walls of a subject's heart. At a cellular level, thepRb^(ser608) is detected in mature cardiomyocytes and Gata4⁺ adultcardiac progenitor cells (CPCs). The increase in phosphorylation can beat least 10, 20, 30, 40, 50, 60, 70, 80, 90, 100, or 200% as compared tothe baseline control. The baseline control can be, for example, levelsof the phosphorylated protein in an untreated sample. The untreatedsample can be from the patient being treated or can be from anotherpatient. Additionally, the baseline control can be from a pool ofuntreated samples such that the baseline control is an average obtainfrom a plurality of patients.

The present disclosure also provides methods to monitor and/or predictprognosis of a subject. In some embodiments, a method of identifying asubject treated for heart disease as a subject with a good prognosis maycomprise obtaining a biological sample comprising cardiac cells from thesubject; measuring phosphorylated retinoblastoma (pRb) levels in thebiological sample; and comparing the phosphorylated retinoblastoma (pRb)levels in the biological sample to a baseline control, wherein anincreased level of pRb in the subject's biological sample when comparedto the baseline control identifies that subject as having a goodprognosis. “Good prognosis” refers to a patient who is expected torecover. In some embodiments, the measuring comprises measuringphosphorylation at Ser⁶⁰⁸ of the retinoblastoma protein. In someembodiments, the measuring may comprise measuring and quantifyingphosphorylation at Ser-608 of the retinoblastoma protein. Thephosphorylated retinoblastoma (pRb) levels may be quantified by anyknown techniques in the art, such as immunohistochemical assays, Westernblot assays, ELISA, biochemical enzymatic assays, or any combinationthereof. In some embodiments, the cardiac cell may be a maturecardiomyocyte and/or a Gata4 positive (Gata4⁺) cardiac progenitor cell(CPC). In some embodiments, the subject may be treated with adult bonemarrow-derived mesenchymal cells (MSCs), adult cardiac stem cells(CSCs), or any combination thereof. In some embodiments, an increase ofat least least 10, 20, 30, 40, 50, 60, 70, 80, 90, 100, or 200% ascompared to the baseline control predicts a good prognosis. The baselinecontrol can be, for example, levels of the phosphorylated protein in anuntreated sample. The untreated sample can be from the patient beingtreated or has the heart disease or can be from another patient.Additionally, the baseline control can be from a pool of untreatedsamples such that the baseline control is an average obtain from aplurality of patients.

In some embodiments, the presence of phosphorylated Rb protein and therelative amounts as compared to a baseline control can be used topredict outcome or prognosis for the diseases discussed herein,including, but not limited to, myocarditis, Coronary Heart Disease,angina, Acute Coronary Syndrome, Aortic Aneurysm and Dissection,arrhythmias, Cardiomyopathy, Congenital Heart Disease, congestive heartfailure or chronic heart failure, pericarditis, and the like.

In another embodiment, a method of monitoring a subject's recoveryfollowing treatment comprises obtaining a sample from a patientundergoing stem cell therapy, measuring expression, function or activityof retinoblastoma (Rb) as compared to a baseline control, wherein theretinoblastoma comprises a hyper-phosphorylated serine at amino acidposition 608 (pRb^(ser608)). In some embodiments, the treatmentcomprises administering to the subject: adult bone marrow-derivedmesenchymal cells (MSCs), adult cardiac stem cells (CSCs), orcombinations of MSCs and CSCs. In some embodiments, the pRb^(ser608)expression, function or activity is increased in subjects treated withMSCs and CSCs as compared to treatment with CSCs or MSCs alone.

In another embodiment, a method of determining the rate of mitosis in asubject's cardiomyocytes comprises obtaining a biological sample from asubject undergoing treatment with stem cells; measuring expression,function or activity of retinoblastoma (Rb) in the biological sample ascompared to a baseline control, wherein the retinoblastoma comprises ahyper-phosphorylated serine at amino acid position 608 (pRb^(ser608))and monitoring the subjects recovery following treatment. In someembodiments, the treatment comprises administering to the subject: adultbone marrow-derived mesenchymal cells (MSCs), adult cardiac stem cells(CSCs), or combinations of MSCs and CSCs. In some embodiments, thepRb^(ser608) expression, function or activity is increased in subjectstreated with MSCs and CSCs as compared to treatment with CSCs or MSCsalone.

In other embodiments, MSC/CSC interaction induces inactivation ofpRb^(ser608) activity, function or expression. In another embodiment,MSC/CSC interaction induces inactivation of ARF activity, function orexpression. In another embodiment, MSC/CSC interaction inducesinactivation of pRb^(ser608) and ARF activity, function or expression.In other embodiments, proliferation of serine-10 phosphorylatedhistone-H3/pRb^(ser608) (HP3⁺/pRB^(ser608+)) alternate reading frame ofInk4a⁽⁻⁾ (ARF⁽⁻⁾) cardiomyocytes, is increased as compared to a baselinecontrol.

In some embodiments, biomarkers for cardiac progenitor cells aredisclosed. In some embodiments, a biomarker comprises phosphorylatedretinoblastoma (pRb) and alternate reading frame of Ink4a (ARF),mutants, variants or fragments thereof. In some embodiments, the markerpRb comprises a hyper-phosphorylated amino acid. In other embodiments,the hyper-phosphorylated amino acid is serine at amino acid position 608(pRb^(ser608)). In some embodiments, detection of marker pRB^(ser608) isdeterminative of Gata4⁺ cardiac stem cells. In other embodiments, markerARF is decreased as compared to a baseline control. The term “baselinecontrol” means as it is used throughout the specification.

In some embodiments it is desirable to express the markers that comprisea biomarker, in a vector and in cells. The applications of suchcombinations are unlimited. The vectors and cells expressing the one ormore biomolecules can be used in assays, kits, drug discovery,diagnostics, prognostics and the like. The cells can be stem cellsisolated from the bone marrow as a progenitor cell, or cells obtainedfrom any other source, such as for example, ATCC.

The biomarkers embodied herein, or cells expressing one or more markerscan be used to screen for factors (such as solvents, small moleculedrugs, peptides, oligonucleotides) or environmental conditions (such asculture conditions or manipulation) that affect the characteristics ofsuch cells and their various progeny.

In some embodiments, a method of identifying a candidate agent tomodulate Rb pathway in a cardiac progenitor cell may comprise contactingthe candidate agent with a population of cardiac progenitor cells(CPCs); and comparing phosphorylated Rb levels in the population ofcardiac progenitor cells contacted with the candidate agent tophosphorylated Rb levels in a population of CPCs not contacted with thecandidate agent, wherein a difference in the phosphorylated Rb levelsidentifies the candidate agent as an agent that modulates the Rb pathwayin the cardiac progenitor cell. The cardiac progenitor cells (CPCs) maybe positive for phosphorylated Rb^(ser608) (pRb^(ser608)), Gata4, or anycombination thereof.

In some embodiments, a method of identifying a candidate agent isprovided said method comprising: (a) contacting a biological sample froma patient with the candidate agent and determining the level ofexpression of one or more biomarkers described herein; (b) determiningthe level of phosphorylation, expression, function or activity of acorresponding biomarker or biomarkers in an aliquot of the biologicalsample not contacted with the candidate agent; (c) observing the effectof the candidate agent by comparing the level of phosphorylation,expression, function or activity of the biomarker or biomarkers in thealiquot of the biological sample contacted with the candidate agent andthe level of phosphorylation, expression, function or activity of thecorresponding biomarker or biomarkers in the aliquot of the biologicalsample not contacted with the candidate agent; and (d) identifying saidagent from said observed effect, wherein an at least 1%, 2%, 5%, 10%,20%, 30%, 40%, 50%, 60%, 70%, 80%, or 90% difference between the levelof phosphorylation, expression, function or activity of the biomarker orcombination of biomarker genes in the aliquot of the biological samplecontacted with the candidate agent and the level of phosphorylation,expression, function or activity of the corresponding biomarker orcombination of biomarker in the aliquot of the biological sample notcontacted with the candidate agent is an indication of an effect of thecandidate agent.

In some embodiments, a candidate agent derived by the methods describedherein are provided.

In some embodiments, a pharmaceutical preparation comprising an agentaccording to the embodiments described herein are provided.

In some embodiments, a method of producing a drug comprising the stepsof (i) synthesizing the candidate agent identified in step (c) above oran analog or derivative thereof in an amount sufficient to provide saiddrug in a therapeutically effective amount to a subject; and/or (ii)combining the drug candidate the candidate agent identified in step (c)above or an analog or derivative thereof with a pharmaceuticallyacceptable carrier.

Other screening applications relate to the testing of pharmaceuticalcompounds for their effect on cardiac muscle tissue maintenance orrepair. Screening may be done either because the compound is designed tohave a pharmacological effect on the cells, or because a compounddesigned to have effects elsewhere may have unintended side effects oncells of this tissue type. The screening can be conducted using any ofthe stem cells or terminally differentiated cells.

In some embodiments, the markers are useful for the identification ofnew drugs in the treatment of cardiovascular diseases and disorders.

In some embodiments, the markers would verify whether a patient'streatment is progressing. For example, the amount, activity orexpression of pRb^(ser608) may change during the course of treatment andreflect normal controls.

Small molecule test compounds or candidate therapeutic compounds caninitially be members of an organic or inorganic chemical library. Asused herein, “small molecules” refers to small organic or inorganicmolecules of molecular weight below about 3,000 Daltons. The smallmolecules can be natural products or members of a combinatorialchemistry library. A set of diverse molecules should be used to cover avariety of functions such as charge, aromaticity, hydrogen bonding,flexibility, size, length of side chain, hydrophobicity, and rigidity.Combinatorial techniques suitable for synthesizing small molecules areknown in the art, e.g., as exemplified by Obrecht and Villalgordo,Solid-Supported Combinatorial and Parallel Synthesis ofSmall-Molecular-Weight Compound Libraries, Pergamon-Elsevier ScienceLimited (1998), and include those such as the “split and pool” or“parallel” synthesis techniques, solid-phase and solution-phasetechniques, and encoding techniques (see, for example, Czarnik, Curr.Opin. Chem. Bio., 1:60 (1997). In addition, a number of small moleculelibraries are commercially available.

Particular screening applications disclosed herein relate to the testingof pharmaceutical compounds in drug research. The reader is referredgenerally to the standard textbook “In vitro Methods in PharmaceuticalResearch”, Academic Press, 1997, and U.S. Pat. No. 5,030,015).Assessment of the activity of candidate pharmaceutical compoundsgenerally involves administering a candidate compound, determining anychange in the morphology, marker phenotype and expression, or metabolicactivity of the cells and function of the cells that is attributable tothe compound (compared with untreated cells or cells treated with aninert compound), and then correlating the effect of the compound withthe observed change.

The screening may be done, for example, either because the compound isdesigned to have a pharmacological effect on certain cell types, orbecause a compound designed to have effects elsewhere may haveunintended side effects. Two or more drugs can be tested in combination(by combining with the cells either simultaneously or sequentially), todetect possible drug-drug interaction effects. In some applications,compounds are screened initially for potential toxicity (Castell et al.,pp. 375-410 in “In vitro Methods in Pharmaceutical Research,” AcademicPress, 1997). Cytotoxicity can be determined in the first instance bythe effect on cell viability, survival, morphology, and expression orrelease of certain markers, receptors or enzymes. Effects of a drug onchromosomal DNA can be determined by measuring DNA synthesis or repair.[³H]thymidine or BrdU incorporation, especially at unscheduled times inthe cell cycle, or above the level required for cell replication, isconsistent with a drug effect. Unwanted effects can also include unusualrates of sister chromatid exchange, determined by metaphase spread. Thereader is referred to A. Vickers (PP 375-410 in “In vitro Methods inPharmaceutical Research,” Academic Press, 1997) for further elaboration.

Examples of methods include, but are not limited to, the standardtextbook In vitro Methods in Pharmaceutical Research, Academic Press,1997 and U.S. Pat. No. 5,030,015. Assessment of the activity ofcandidate pharmaceutical compounds generally involves combining thecells with the candidate compound, either alone or in combination withother drugs. The investigator determines any change in the morphology,marker phenotype, or functional activity of the cells that isattributable to the compound (compared with untreated cells or cellstreated with an inert compound), and then correlates the effect of thecompound with the observed change.

Cytotoxicity can be determined in the first instance by the effect oncell viability, survival, morphology, and the expression of certainmarkers and receptors. Effects of a drug on chromosomal DNA can bedetermined by measuring DNA synthesis or repair.

[³H]-thymidine or BrdU incorporation, especially at unscheduled times inthe cell cycle, or above the level required for cell replication, isconsistent with a drug effect. Unwanted effects can also include unusualrates of sister chromatid exchange, determined by metaphase spread. Thereader is referred to A. Vickers (pp 375-410 in In vitro Methods inPharmaceutical Research, Academic Press, 1997) for further elaboration.

Effect of cell function can be assessed using any standard assay toobserve phenotype or activity of cardiomyocytes, such as markerexpression, receptor binding, contractile activity, orelectrophysiology, either in cell culture or in vivo. Pharmaceuticalcandidates can also be tested for their effect on contractile activity,such as whether they increase or decrease the extent or frequency ofcontraction. Where an effect is observed, the concentration of thecompound can be titrated to determine the median effective dose (ED₅₀).

An agent that inhibits the function of Rb and/or ARF may be formulatedas a pharmaceutical composition or medicament. Pharmaceuticalcompositions adapted for direct administration include, withoutlimitation, lyophilized powders or aqueous or non-aqueous sterileinjectable solutions or suspensions, which may further containantioxidants, buffers, bacteriostats and solutes that render thecompositions substantially isotonic with the blood of an intendedrecipient. Other components that may be present in such compositionsinclude water, alcohols, polyols, glycerin and vegetable oils, forexample. Extemporaneous injection solutions and suspensions may beprepared from sterile powders, granules and tablets. The agents may besupplied, for example but not by way of limitation, as a lyophilizedpowder which is reconstituted with sterile water or saline prior toadministration to the patient.

Pharmaceutical compositions may comprise a pharmaceutically acceptablecarrier. Suitable pharmaceutically acceptable carriers includeessentially chemically inert and nontoxic compositions that do notinterfere with the effectiveness of the biological activity of thepharmaceutical composition. Examples of suitable pharmaceutical carriersinclude, but are not limited to, water, saline solutions, glycerolsolutions, ethanol, N-(1(2,3-dioleyloxy) propyl)N,N,N-trimethylammoniumchloride (DOTMA), diolesylphosphotidyl-ethanolamine (DOPE), andliposomes. Such compositions should contain a therapeutically effectiveamount of the compound, together with a suitable amount of carrier so asto provide the form for direct administration to the patient.

The composition may be in the form of a pharmaceutically acceptable saltwhich includes, without limitation, those formed with free amino groupssuch as those derived from hydrochloric, phosphoric, acetic, oxalic,tartaric acids, etc., and those formed with free carboxyl groups such asthose derived from sodium, potassium, ammonium, calcium, ferrichydroxides, isopropylamine, triethylamine, 2-ethylarnino ethanol,histidine, procaine, etc.

In various embodiments, the pharmaceutical composition is directlyadministered to the area of the injury, such as to the cardiac tissueby, for example, local infusion during surgery, topical application(e.g., in conjunction with a wound dressing after surgery), injection,means of a catheter, means of a suppository, or means of an implant. Animplant can be of a porous, non-porous, or gelatinous material,including membranes, such as sialastic membranes, or fibers.Suppositories generally contain active ingredients in the range of 0.5%to 10% by weight.

In other embodiments, a controlled release system can be placed inproximity of the target site. For example, a micropump may delivercontrolled doses directly into the area of the target site, such as tothe cardiac tissue, thereby finely regulating the timing andconcentration of the pharmaceutical composition.

In accordance some embodiments, the agent that inhibits the function ofRb and/or ARF is delivered to the patient by direct administration.Accordingly, the agent may be administered, without limitation, by oneor more direct injections into the target site, by continuous ordiscontinuous perfusion into the target site, by introduction of areservoir of the agent, by introduction of a slow-release apparatus intothe target site, by introduction of a slow-release formulation into thetarget site, and/or by direct application onto the target site. By themode of administration into the target site, introduction of the agentinto a blood vessel or lymphatic vessel that substantially directlyflows into the area of the target site, is also contemplated. In eachcase, the pharmaceutical composition is administered in at least anamount sufficient to achieve the endpoint, and if necessary, comprises apharmaceutically acceptable carrier.

In some embodiments, the pharmaceutical carrier may include, withoutlimitation, binders, coating, disintegrants, fillers, diluents, flavors,colors, lubricants, glidants, preservatives, sorbents, sweeteners,conjugated linoleic acid (CLA), gelatin, beeswax, purified water,glycerol, any type of oil, including, without limitation, fish oil orsoybean oil, or the like. Pharmaceutical compositions of thepeptides/compounds also can comprise suitable solid or gel phasecarriers or excipients. Examples of such carriers or excipients includebut are not limited to calcium carbonate, calcium phosphate, varioussugars, starches, cellulose derivatives, gelatin, and polymers such as,e.g., polyethylene glycols.

The agents disclosed herein can be administered, for example, in theconventional manner by any route where they are active. Administrationcan be systemic, parenteral, topical, or oral. For example,administration can be, but is not limited to, parenteral, subcutaneous,intravenous, intramuscular, intraperitoneal, transdermal, oral, buccal,or ocular routes, or intravaginally, by inhalation, by depot injections,or by implants. Thus, modes of administration for the agents (eitheralone or in combination with other pharmaceuticals) can be, but are notlimited to, sublingual, injectable (including short-acting, depot,implant and pellet forms injected subcutaneously or intramuscularly), orby use of vaginal creams, suppositories, pessaries, vaginal rings,rectal suppositories, intrauterine devices, and transdermal forms suchas patches and creams.

For oral administration, the agents can be formulated readily bycombining these agents with pharmaceutically acceptable carriers wellknown in the art. Such carriers enable the agents, compounds, cells,etc. to be formulated as tablets, pills, dragees, capsules, liquids,gels, syrups, slurries, suspensions and the like, for oral ingestion bya patient to be treated. Pharmaceutical preparations for oral use can beobtained by adding a solid excipient, optionally grinding the resultingmixture, and processing the mixture of granules, after adding suitableauxiliaries, if desired, to obtain tablets or dragee cores. Suitableexcipients include, but are not limited to, fillers such as sugars,including, but not limited to, lactose, sucrose, mannitol, and sorbitol;cellulose preparations such as, but not limited to, maize starch, wheatstarch, rice starch, potato starch, gelatin, gum tragacanth, methylcellulose, hydroxypropylmethyl-cellulose, sodium carboxymethylcellulose,and polyvinylpyrrolidone (PVP). If desired, disintegrating agents can beadded, such as, but not limited to, the cross-linked polyvinylpyrrolidone, agar, or alginic acid or a salt thereof such as sodiumalginate.

Dragee cores can be provided with suitable coatings. For this purpose,concentrated sugar solutions can be used, which can optionally containgum arabic, talc, polyvinyl pyrrolidone, carbopol gel, polyethyleneglycol, and/or titanium dioxide, lacquer solutions, and suitable organicsolvents or solvent mixtures. Dyestuffs or pigments can be added to thetablets or dragee coatings for identification or to characterizedifferent combinations of active peptides/compound doses.

Pharmaceutical preparations which can be used orally include, but arenot limited to, push-fit capsules made of gelatin, as well as soft,sealed capsules made of gelatin and a plasticizer, such as glycerol orsorbitol. The push-fit capsules can contain the active ingredients inadmixture with filler such as, e.g., lactose, binders such as, e.g.,starches, and/or lubricants such as, e.g., talc or magnesium stearateand, optionally, stabilizers. In soft capsules, the activepeptides/compounds can be dissolved or suspended in suitable liquids,such as fatty oils, liquid paraffin, or liquid polyethylene glycols. Inaddition, stabilizers can be added. All formulations for oraladministration should be in dosages suitable for such administration.

For buccal administration, the compositions can take the form of, e.g.,tablets or lozenges formulated in a conventional manner.

For administration by inhalation, the compositions for use areconveniently delivered in the form of an aerosol spray presentation frompressurized packs or a nebulizer, with the use of a suitable propellant,e.g., dichlorodifluoromethane, trichlorofluoromethane,dichlorotetrafluoroethane, carbon dioxide or other suitable gas. In thecase of a pressurized aerosol the dosage unit can be determined byproviding a valve to deliver a metered amount. Capsules and cartridgesof, e.g., gelatin for use in an inhaler or insufflator can be formulatedcontaining a powder mix of the peptides/compound and a suitable powderbase such as lactose or starch.

The compositions can also be formulated in rectal compositions such assuppositories or retention enemas, e.g., containing conventionalsuppository bases such as cocoa butter or other glycerides.

In addition to the formulations described previously, the compositionscan also be formulated as a depot preparation. Such long actingformulations can be administered by implantation (for examplesubcutaneously or intramuscularly) or by intramuscular injection.

Depot injections can be administered at about 1 to about 6 months orlonger intervals. Thus, for example, the peptides/compounds can beformulated with suitable polymeric or hydrophobic materials (for exampleas an emulsion in an acceptable oil) or ion exchange resins, or assparingly soluble derivatives, for example, as a sparingly soluble salt.

In transdermal administration, the compositions, for example, can beapplied to a plaster, or can be applied by transdermal, therapeuticsystems that are consequently supplied to the organism.

The compositions can also be administered in combination with otheractive ingredients, such as, for example, adjuvants, proteaseinhibitors, or other compatible drugs or compounds where suchcombination is seen to be desirable or advantageous in achieving thedesired effects of the methods described herein.

In some embodiments, the disintegrant component comprises one or more ofcroscarmellose sodium, carmellose calcium, crospovidone, alginic acid,sodium alginate, potassium alginate, calcium alginate, an ion exchangeresin, an effervescent system based on food acids and an alkalinecarbonate component, clay, talc, starch, pregelatinized starch, sodiumstarch glycolate, cellulose floc, carboxymethylcellulose,hydroxypropylcellulose, calcium silicate, a metal carbonate, sodiumbicarbonate, calcium citrate, or calcium phosphate.

In some embodiments, the diluent component comprises one or more ofmannitol, lactose, sucrose, maltodextrin, sorbitol, xylitol, powderedcellulose, microcrystalline cellulose, carboxymethylcellulose,carboxyethylcellulose, methylcellulose, ethylcellulose,hydroxyethylcellulose, methylhydroxyethylcellulose, starch, sodiumstarch glycolate, pregelatinized starch, a calcium phosphate, a metalcarbonate, a metal oxide, or a metal aluminosilicate.

In some embodiments, the optional lubricant component, when present,comprises one or more of stearic acid, metallic stearate, sodium stearylfumarate, fatty acid, fatty alcohol, fatty acid ester, glycerylbehenate, mineral oil, vegetable oil, paraffin, leucine, silica, silicicacid, talc, propylene glycol fatty acid ester, polyethoxylated castoroil, polyethylene glycol, polypropylene glycol, polyalkylene glycol,polyoxyethylene-glycerol fatty ester, polyoxyethylene fatty alcoholether, polyethoxylated sterol, polyethoxylated castor oil,polyethoxylated vegetable oil, or sodium chloride.

As discussed herein various techniques can be used to identify or detectcertain markers. The following are non-limiting examples of suchtechniques. In general, using nucleic acid microarrays, test and controlmRNA samples from test and control tissue samples are reversetranscribed and labeled to generate cDNA probes. The probes are thenhybridized to an array of nucleic acids immobilized on a solid support.The array is configured such that the sequence and position of eachmember of the array is known. For example, a selection of genes thathave potential to be expressed in certain disease states may be arrayedon a solid support. Hybridization of a labeled probe with a particulararray member indicates that the sample from which the probe was derivedexpresses that gene. Differential gene expression analysis of diseasetissue can provide valuable information. Microarray technology utilizesnucleic acid hybridization techniques and computing technology toevaluate the mRNA expression profile of thousands of genes within asingle experiment. (see, e.g., WO 01/75166 published Oct. 11, 2001;(See, for example, U.S. Pat. Nos. 5,700,637, 5,445,934, and 5,807,522,Lockart, Nature Biotechnology, 14:1675-1680 (1996); Cheung, V. G. etal., Nature Genetics 21(Suppl):15-19 (1999) for a discussion of arrayfabrication). DNA microarrays are miniature arrays containing genefragments that are either synthesized directly onto or spotted ontoglass or other substrates. Thousands of genes are usually represented ina single array. A typical microarray experiment involves the followingsteps: 1) preparation of fluorescently labeled target from RNA isolatedfrom the sample, 2) hybridization of the labeled target to themicroarray, 3) washing, staining, and scanning of the array, 4) analysisof the scanned image and 5) generation of gene expression profiles.Currently two main types of DNA microarrays are being used:oligonucleotide (usually 25 to 70 mers) arrays and gene expressionarrays containing PCR products prepared from cDNAs. In forming an array,oligonucleotides can be either prefabricated and spotted to the surfaceor directly synthesized on to the surface (in situ). The AffymetrixGeneChip™ system is a commercially available microarray system whichcomprises arrays fabricated by direct synthesis of oligonucleotides on aglass surface.

Probes and gene arrays can also be used. Oligonucleotides, usually 25mers, are directly synthesized onto a glass wafer by a combination ofsemiconductor-based photolithography and solid phase chemical synthesistechnologies. Each array can contain up to 400,000 differentoligonucleotides and each oligonucleotide is present in millions ofcopies. Since oligonucleotide probes are synthesized in known locationson the array, the hybridization patterns and signal intensities can beinterpreted in terms of gene identity and relative expression levels bythe Affymetrix Microarray Suite software. Each gene is represented onthe array by a series of different oligonucleotide probes. Each probepair consists of a perfect match oligonucleotide and a mismatcholigonucleotide. The perfect match probe has a sequence exactlycomplimentary to the particular gene and thus measures the expression ofthe gene. The mismatch probe differs from the perfect match probe by asingle base substitution at the center base position, disturbing thebinding of the target gene transcript. This helps to determine thebackground and nonspecific hybridization that contributes to the signalmeasured for the perfect match oligonucleotide. The Microarray Suitesoftware subtracts the hybridization intensities of the mismatch probesfrom those of the perfect match probes to determine the absolute orspecific intensity value for each probe set. Probes are chosen based oncurrent information from GenBank and other nucleotide repositories. Thesequences are believed to recognize unique regions of the 3′ end of thegene. A GeneChip Hybridization Oven (“rotisserie” oven) is used to carryout the hybridization of up to 64 arrays at one time. The fluidicsstation performs washing and staining of the probe arrays. It iscompletely automated and contains four modules, with each module holdingone probe array. Each module is controlled independently throughMicroarray Suite software using preprogrammed fluidics protocols. Thescanner is a confocal laser fluorescence scanner which measuresfluorescence intensity emitted by the labeled cRNA bound to the probearrays. The computer workstation with Microarray Suite software controlsthe fluidics station and the scanner. Microarray Suite software cancontrol up to eight fluidics stations using preprogrammed hybridization,wash, and stain protocols for the probe array. The software alsoacquires and converts hybridization intensity data into apresence/absence call for each gene using appropriate algorithms.Finally, the software detects changes in gene expression betweenexperiments by comparison analysis and formats the output into .txtfiles, which can be used with other software programs for further dataanalysis.

The expression of a selected biomarker may also be assessed by examininggene deletion or gene amplification. Gene deletion or amplification maybe measured by any one of a wide variety of protocols known in the art,for example, by conventional Southern blotting, Northern blotting toquantitate the transcription of mRNA (Thomas, Proc. Natl. Acad. Sci.USA, 77:5201-5205 (1980)), dot blotting (DNA analysis), or in situhybridization (e.g., FISH), using an appropriately labeled probe,cytogenetic methods or comparative genomic hybridization (CGH) using anappropriately labeled probe.

In some embodiments, a polypeptide corresponding to a marker isdetected. In some embodiments, an antibody or aptamer capable of bindingto a polypeptide corresponding to a marker described herein, or anantibody with a detectable label, is used. Antibodies can be polyclonalor monoclonal. An intact antibody, or a fragment thereof, e.g., Fab orF(ab′)₂ can be also used.

Proteins from individuals can also be isolated using techniques that arewell-known to those of skill in the art. The protein isolation methodsemployed can, e.g., be such as those described in Harlow & Lane (1988),supra. A variety of formats can be employed to determine whether asample contains a protein that binds to a given antibody. Expression ofvarious biomarkers in a sample can be analyzed by a number ofmethodologies, many of which are known in the art and understood by theskilled artisan, including but not limited to, immunohistochemicaland/or Western analysis, quantitative blood based assays (as for exampleSerum ELISA) (to examine, for example, levels of protein expression),biochemical enzymatic activity assays, in situ hybridization, Northernanalysis and/or PCR analysis of mRNAs, as well as any one of the widevariety of assays that can be performed by gene and/or tissue arrayanalysis. Typical protocols for evaluating the status of genes and geneproducts are found, for example in Ausubel et al. eds., 1995, CurrentProtocols In Molecular Biology, Units 2 (Northern Blotting), 4 (SouthernBlotting), 15 (Immunoblotting) and 18 (PCR Analysis). A skilled artisancan readily adapt known protein/antibody detection methods for use indetermining whether cells express a marker and/or the relativeconcentration of that specific polypeptide expression product in bloodor other body tissues.

In some embodiments, a sample may be contacted with an antibody specificfor said biomarker under conditions sufficient for an antibody-biomarkercomplex to form, and then detecting said complex. The presence of thebiomarker may be detected in a number of ways, such as by Westernblotting and ELISA procedures for assaying a wide variety of tissues andsamples, including plasma or serum. A wide range of immunoassaytechniques using such an assay format are available, see, e.g., U.S.Pat. Nos. 4,016,043, 4,424,279 and 4,018,653. These include bothsingle-site and two-site or “sandwich” assays of the non-competitivetypes, as well as in the traditional competitive binding assays. Theseassays also include direct binding of a labeled antibody to a targetbiomarker.

Sandwich assays are commonly used assays. A number of variations of thesandwich assay technique exist, and all are intended to be encompassedby the present disclosure. Briefly, in a typical forward assay, anunlabeled antibody is immobilized on a solid substrate, and the sampleto be tested brought into contact with the bound molecule. After asuitable period of incubation, for a period of time sufficient to allowformation of an antibody-antigen complex, a second antibody specific tothe antigen, labeled with a reporter molecule capable of producing adetectable signal is then added and incubated, allowing time sufficientfor the formation of another complex of antibody-antigen-labeledantibody. Any unreacted material is washed away, and the presence of theantigen is determined by observation of a signal produced by thereporter molecule. The results may either be qualitative, by simpleobservation of the visible signal, or may be quantitated by comparingwith a control sample containing known amounts of biomarker.

Variations on the forward assay include a simultaneous assay, in whichboth sample and labeled antibody are added simultaneously to the boundantibody. These techniques are well known to those skilled in the art,including any minor variations as will be readily apparent. In a typicalforward sandwich assay, a first antibody having specificity for thebiomarker is either covalently or passively bound to a solid surface.The solid surface is typically glass or a polymer, the most commonlyused polymers being cellulose, polyacrylamide, nylon, polystyrene,polyvinyl chloride or polypropylene. The solid supports may be in theform of tubes, beads, discs of microplates, or any other surfacesuitable for conducting an immunoassay. The binding processes arewell-known in the art and generally consist of cross-linking covalentlybinding or physically adsorbing, the polymer-antibody complex is washedin preparation for the test sample. An aliquot of the sample to betested is then added to the solid phase complex and incubated for aperiod of time sufficient (e.g. 2-40 minutes or overnight if moreconvenient) and under suitable conditions (e.g. from room temperature to40° C. such as between 25° C. and 32° C. inclusive) to allow binding ofany subunit present in the antibody. Following the incubation period,the antibody subunit solid phase is washed and dried and incubated witha second antibody specific for a portion of the biomarker. The secondantibody is linked to a reporter molecule which is used to indicate thebinding of the second antibody to the molecular marker.

In some embodiments, a method involves immobilizing the targetbiomarkers in the sample and then exposing the immobilized target tospecific antibody which may or may not be labeled with a reportermolecule can be used. Depending on the amount of target and the strengthof the reporter molecule signal, a bound target may be detectable bydirect labeling with the antibody. Alternatively, a second labeledantibody, specific to the first antibody is exposed to the target-firstantibody complex to form a target-first antibody-second antibodytertiary complex. The complex is detected by the signal emitted by thereporter molecule. By “reporter molecule”, as used in the presentspecification, is meant a molecule which, by its chemical nature,provides an analytically identifiable signal which allows the detectionof antigen-bound antibody. The most commonly used reporter molecules inthis type of assay are either enzymes, fluorophores or radionuclidecontaining molecules (i.e. radioisotopes) and chemiluminescentmolecules.

In the case of an enzyme immunoassay, an enzyme is conjugated to thesecond antibody, generally by means of glutaraldehyde or periodate. Aswill be readily recognized, however, a wide variety of differentconjugation techniques exist, which are readily available to the skilledartisan.

Commonly used enzymes include horseradish peroxidase, glucose oxidase,-galactosidase and alkaline phosphatase, amongst others. The substratesto be used with the specific enzymes are generally chosen for theproduction, upon hydrolysis by the corresponding enzyme, of a detectablecolor change. Examples of suitable enzymes include alkaline phosphataseand peroxidase. It is also possible to employ fluorogenic substrates,which yield a fluorescent product rather than the chromogenic substratesnoted above. In all cases, the enzyme-labeled antibody is added to thefirst antibody-molecular marker complex, allowed to bind, and then theexcess reagent is washed away. A solution containing the appropriatesubstrate is then added to the complex of antibody-antigen-antibody. Thesubstrate will react with the enzyme linked to the second antibody,giving a qualitative visual signal, which may be further quantitated,usually spectrophotometrically, to give an indication of the amount ofbiomarker which was present in the sample. Alternately, fluorescentcompounds, such as fluorescein and rhodamine, may be chemically coupledto antibodies without altering their binding capacity. When activated byillumination with light of a particular wavelength, thefluorochrome-labeled antibody adsorbs the light energy, inducing a stateto excitability in the molecule, followed by emission of the light at acharacteristic color visually detectable with a light microscope. As inthe EIA, the fluorescent labeled antibody is allowed to bind to thefirst antibody-molecular marker complex. After washing off the unboundreagent, the remaining tertiary complex is then exposed to the light ofthe appropriate wavelength, the fluorescence observed indicates thepresence of the molecular marker of interest. Immunofluorescence and EIAtechniques are both very well established in the art. However, otherreporter molecules, such as radioisotope, chemiluminescent orbioluminescent molecules, may also be employed.

Methods described herein can also include protocols which examine thepresence and/or expression of mRNAs, in a tissue or cell sample. Methodsfor the evaluation of mRNAs in cells are well known and include, forexample, hybridization assays using complementary DNA probes (such as insitu hybridization using labeled riboprobes, Northern blot and relatedtechniques) and various nucleic acid amplification assays (such asRT-PCR and other amplification type detection methods, such as, forexample, branched DNA, SISBA, TMA and the like).

In some embodiments, the level of mRNA corresponding to the marker canbe determined both by in situ and by in vitro formats in a biologicalsample using methods known in the art. Many expression detection methodsuse isolated RNA. For in vitro methods, any RNA isolation technique thatdoes not select against the isolation of mRNA can be utilized for thepurification of RNA from cells. See, e.g., Ausubel et al., Ed., Curr.Prot. Mol. Biol., John Wiley & Sons, NY (1987-1999). Additionally, largenumbers of tissue samples can readily be processed using techniqueswell-known to those of skill in the art, such as, e.g., the single-stepRNA isolation process of U.S. Pat. No. 4,843,155. The isolated mRNA canbe used in hybridization or amplification assays that include, but arenot limited to, Southern or Northern analyses, PCR analyses and probearrays. In some embodiments, a method for the detection of mRNA levelscomprises contacting the isolated mRNA with a nucleic acid molecule(probe) that can hybridize to the mRNA encoded by the gene beingdetected. The nucleic acid probe can be, e.g., a full-length cDNA, or aportion thereof, such as an oligonucleotide of at least 7, 15, 30, 50,100, 250 or 500 nucleotides in length and sufficient to specificallyhybridize under stringent conditions to a mRNA encoding a markerdescribed herein.

In some embodiments, the mRNA is immobilized on a solid surface andcontacted with a probe, for example, by running the isolated mRNA on anagarose gel and transferring the mRNA from the gel to a membrane, suchas nitrocellulose. In an alternative format, the probe(s) areimmobilized on a solid surface and the mRNA is contacted with theprobe(s), for example, in an Affymetrix gene chip array. A skilledartisan can readily adapt known mRNA detection methods for use indetecting the level of mRNA encoded by the markers described herein.

For in situ methods, mRNA does not need to be isolated form the cellsprior to detection. In such methods, a cell or tissue sample isprepared/processed using known histological methods. The sample is thenimmobilized on a support, typically a glass slide, and then contactedwith a probe that can hybridize to mRNA that encodes the marker.

As an alternative to making determinations based on the absoluteexpression level of the marker, determinations may be based on thenormalized expression level of the marker. Expression levels arenormalized by correcting the absolute expression level of a marker bycomparing its expression to the expression of a gene that is not amarker, e.g., a housekeeping gene that is constitutively expressed.Suitable genes for normalization include housekeeping genes, such as theactin gene or epithelial cell-specific genes. This normalization allowsthe comparison of the expression level in one sample, e.g., a patientsample, to another sample or between samples from different sources.

Alternatively, the expression level can be provided as a relativeexpression level. To determine a relative expression level of a marker,the level of expression of the marker is determined for 10 or moresamples of normal versus disease biological samples, or 50 or moresamples, prior to the determination of the expression level for thesample in question. The mean expression level of each of the genesassayed in the larger number of samples is determined and this is usedas a baseline expression level for the marker. The expression level ofthe marker determined for the test sample (absolute level of expression)is then divided by the mean expression value obtained for that marker.This provides a relative expression level.

The choice of the cell source is dependent on the use of the relativeexpression level. Using expression found in normal tissues as a meanexpression score aids in validating whether the marker assayed isspecific (versus normal cells). In addition, as more data isaccumulated, the mean expression value can be revised, providingimproved relative expression values based on accumulated data.

All documents mentioned herein are incorporated herein by reference. Allpublications and patent documents cited in this application areincorporated by reference for all purposes to the same extent as if eachindividual publication or patent document were so individually denoted.By their citation of various references in this document, Applicants donot admit any particular reference is “prior art.”

EXAMPLES

While various embodiments have been described above, it should beunderstood that they have been presented by way of example only, and notlimitation. Numerous changes to the disclosed embodiments can be made inaccordance with the disclosure herein without departing from the spiritor scope of the embodiments. Thus, the breadth and scope of the claimsshould not be limited without an express and explicit disclaimer.

Example 1: Function of Rb in Cardiomyogenisis

Methods

Briefly, hCSCs and hMSCs, in combination or alone, were administered toswine hearts following myocardial infarction (MI) and cardiac pRbactivity was assessed. Stem cell transplantation was performed 2 weeksafter MI, as described (Williams A R, Hatzistergos K E, et al. Enhancedeffect of human cardiac stem cells and bone marrow mesenchymal stemcells to reduce infarct size and restore cardiac function aftermyocardial infarction. Circulation. 2013 Jan. 15; 127(2):213-23 (Epub2012 Dec. 5)). The following groups were studied: 200M hMSCs, 1M hCSCs,200M hMSC plus 1M hCSC or placebo (n=3 each). All human cells wereobtained from unrelated coded donors, using previously described methods(Hare J M, et al. JAMA 2012 Nov. 6; 1-11; Bolli R, et al. Lancet 2011Nov. 26; 378(9806):1847-57).

All animal protocols were reviewed and approved by the University ofMiami Institutional Animal Use and Care Committee.

Myocardial Infarction

The porcine model of MI was performed as recently described(Hatzistergos K E et al. Bone Marrow Mesenchymal Stem Cells StimulateCardiac Stem Cell Proliferation and Differentiation. Circ Res 2010 Jul.29; Williams A R, et al. Enhanced effect of human cardiac stem cells andbone marrow mesenchymal stem cells to reduce infarct size and restorecardiac function after myocardial infarction. Circulation. In press2012). Briefly, Yorkshire swine (35-40 kg, n=22) underwent aclosed-chest, ischemia-reperfusion protocol to generate a model ofanterior wall MI. Using angioplasty techniques, balloon occlusion of theleft anterior descending coronary artery immediately beyond the firstdiagonal branch for 90 minutes was performed to induce MI and fullreperfusion was confirmed by angiography after balloon deflation.

Cell Isolation and Culturing

Explanted cardiac tissue was harvested following IRB approval andinformed consent, from the core of apical tissue removed duringimplantation of a left ventricle assist device (LVAD) in a single humanmale donor. CSCs expressing c-kit were isolated from the enzymaticdissociated myocardial sample using magnetic microbeads coupled toanti-human CD117 antibody (Miltenyi Biotech), as previously described(Bolli R, et al. Lancet 2011 Nov. 26; 378(9806):1847-57). Afterdissociation, cells were plated at a high density, amplified, harvested,and cryopreserved.

For hMSCs isolation, a bone marrow (BM) aspirate was obtained from theiliac crest of a human male donor. Human MSCs were isolated from otherBM cells by Ficoll density centrifugation and plastic adherence aspreviously described (Hare J M, et al. JAMA 2012 Nov. 6; 1-11.); hMSCswere amplified, harvested, and cryopreserved. On the morning of stemcell injection, cells were thawed, washed and resuspended in phosphatebuffered saline (PBS). For hMSC alone injections (n=3), 200 millionhMSCs were suspended in 6 ml of PBS, and for hCSC alone injection (n=3),1 million hCSCs were suspended in 3 ml of PBS. For the combinedinjections (n=3), 1 million hCSCs and 200 million hMSCs were suspendedin a total volume of 6 ml of PBS and mixed before injection. For placeboinjections (n=3), 6 ml of PBS was administered. All cells or placeboinjections were divided into 10 equal volume aliquots and injectedtransepicardially with a 27 gauge needle.

Cardiac Magnetic Resonance Imaging

CMR studies were conducted on a Siemens Trio 3T Tim (Erlangen, Germany)scanner with Syngo MR software using a 16-channel body surface coil withECG gating and short breath-hold acquisition. The QMass Software (Medis,Leiden, Netherlands) was employed to calculate scar size.

Cell Transplantation

The xenogeneic model of cell therapy was performed as previouslydescribed (Williams A R, et al. Circulation. In press 2012). At 14 dayspost-MI, animals underwent thoracoscopy guided direct transepicardialstem cell (n=9) or placebo injection (n=3). Coronary angiography from MIinduction and delayed enhancement CMR images were reviewed to definecoronary anatomy and infarct extent. A left mini-thoracotomy was createdwith a small 4-5 cm incision in the 5th anterior/lateral intercostalspace, and the left plural cavity entered under direct visualization. A5 mm port was placed in the 6th or 7th intercostal space, and a 5 mmendoscope (Karl Storz, Tuttlingen, Germany) inserted into the left chestcavity. The pericardium was opened and infarct area identified by wallmotion abnormalities and correlation with coronary anatomy. A curved27-guage needle was inserted tangentially into the myocardium and 10separate injections administered to the infarct border zone. Adequatehemostasis of needle puncture sites was achieved with gentle fingerpressure. A 12-French chest tube was inserted into the left pleuralcavity via the port incision, and tunneled through the chest wall. Allincisions were closed and the chest tube placed to −20 cm of underwatersuction to evacuate the pnuemothorax. Fluoroscopy was done to confirmlung expansion and the chest tube removed prior to extubation. Animalswere recovered and provided adequate post-operative analgesia with atransdermal fentanyl patch (75 mcg/hr) for 3 days and bupernorpherine(0.03 mg/kg IM) immediately post-procedure. All animals wereeuthanatized at 6 weeks post MI.

Immunohistochemistry

Immunofluorescence analyses and confocal microscopy were performed in 5μm-thick, formalin-fixed, paraffin-embedded tissue sections aspreviously described (Hatzistergos K E, et al. Circ Res 2010; 107(7):913-922). Briefly, after deparaffinizing and rehydrating the tissuesections, antigen unmasking was performed by microwaving the slides for20 min in citrate buffer Solution, pH=6 (Dako). Sections were blockedfor 1 h with 10% normal donkey serum (Millipore) followed by overnightincubation at 4° C. with the primary antibody. The following antibodieswere used: anti-porcine C-kit (mouse monoclonal), anti-human c-kit(rabbit polyclonal; DAKO), tropomyosin (mouse monoclonal; Abcam),ser-608 pRb (Goat polyclonal; Santa Cruz Biotechnologies), ARF (rabbitpolyclonals; Novus Biologicals and Abcam), GATA-4 (Rabbit and goatpolyclonals; Santa Cruz Biotechnologies), WT1 (rabbit polyclonal; SantaCruz Biotechnologies), cardiac myosin light chain-2v (Rabbit polyclonal;Novus biological), Laminin (goat polyclonal; Abcam) and ser-10phosphorylated histone-H3 (mouse monoclonal; Abcam). The next day,antibodies were visualized by incubating the sections for 1 h at 37° C.with FITC, Cy3 or Cy5-conjugated F(ab′)2 fragments of affinity-purifiedsecondary antibodies (Jackson Immunoresearch). Slides werecounterstained with DAPI, mounted with ProLong Antifade Gold reagent(Life Technologies) and stored at 4° C. until further examination.Microscopic evaluations and image acquisitions were performed with aZeiss LSM-710 Confocal Microscope (Carl Zeiss). The Carl Zeiss ZENsoftware (2009, light edition) was used for analyses.

Statistical Analysis

All values are expressed as means (+/−SEM). Differences in pRb^(ser608)between groups were calculated with a Kruskal-Wallis ANOVA. A pairedStudent's t-test was employed for calculating differences in myocytecross-sectional areas. Linear regression analysis was used to test theregression of cell numbers with cMRI-based scar size reductions.GraphPad Prism (Version 4.03, La Jolla, Calif.) was used to analyze alldata and plot graphs. A p-value of less than 0.05 was consideredstatistically significant.

Results

pRb^(Ser608) reflects host regenerative cardiac cells and is enhanced byMSCs/CSCs interactions. Because hyper-phosphorylation of pRb at Ser-608inhibits pRb activity and is a hallmark of regeneration in injured adultnewt hearts, we tested whether pRb^(ser608) participates in mammalianmyocardial regenerative activity following cell-based therapy. However,there was no expectation of success in whether pRb would work in thesame manner in mammalian heart muscle because the newt physiology andregenerative systems are significantly different. For example, Rb inhuman stem cells and disease pathways operates in very different ways,when compared to stem cells and disease pathways in other species.Therefore, any experimental information regarding the mechanisms bywhich Rb controls cell-cycle and cell-fate decisions in mice or newtsdoes not necessarily mean that these mechanisms are operative in humans.In addition, ARF has no homologues in lower vertebrates, such as thenewt and the zebrafish, which display regenerative capacity. Forexample, a newt can regenerate a limb after amputation, whereas thisprocess does not occur in humans. Thus, although regeneration occurs innewts and neonatal mice, through various signaling pathways, thisphenomenon in the adult mammal is non-obvious. Therefore, it wasuncertain whether pRb would have a role in regenerating heart muscle.Therefore, tests were performed as to whether pRb^(Ser608) was absentfrom the compact myocardial ventricular wall in normal myocardium andwas restricted to epicardial and endocardial cells in healthy porcinemyocardium (FIG. 6). Following ischemic injury, its expression increasedsubstantially in the compact ventricular myocardial wall wherepRb^(Ser608) was identified in both mature cardiomyocytes and Gata4⁺CPCs (immature cells expressing Gata4), but not in cells of extracardiaclineage (FIGS. 1A, 1B).

To assess the impact of cell therapy on endogenous cell inactivation ofpRb, quantified pRb^(Ser608+) CPCs were quantified in the four celltreatment groups. Compared to placebo, pRb was increased in abundancefollowing stem cell therapy (p<0.0001) (FIG. 1 c,d). Relative to hMSCs,hCSCs induced pRb^(Ser608) in host CPCs to a greater extent, both in theinfarct and border zones. When hCSCs and hMSCs were coinjected, thiseffect was enhanced by ˜1.5-fold compared to each cell type alone and by˜3 fold compared to placebo (p<0.0001) (FIGS. 1C, 1D).

Abundance of Host Progenitor Cells

To determine whether pRbser608 participates in cell-cycle or cell-fatedecisions in endogenous CPCs, differences in cells expressing severalmarkers known to identify adult CPCs were quantified, including Wt1⁺,c-kit⁺ and Gata4⁺. No differences were found in the myocardial abundancein Wt1⁺, c-kit⁺ or Gata4⁺ CPCs between the four groups at 4 weeks.Furthermore, although co-localization with the mitotic marker serine-10phosphorylated histone-H3 (HP3) revealed a substantial number of theseCPCs undergoing cell division, the differences in replicating CPCsbetween groups also was not affected by the different cell therapy(p=0.08 and p=0.36 in infarct and border zones respectively) (FIG. 2).Thus, similar to the role of pRb in embryonic stem cell-derived CPCs,these findings provide evidence that pRbSer608 determines lineagecommitment rather than proliferative activity in adult Gata4⁺ CPCs (FIG.2).

pRb^(Ser608) in Host Cardiomyocytes

Investigated next was the role of pRb^(Ser608) in endogenouscardiomyocytes. Confocal immunofluorescence demonstrated that neitherhCSCs nor hMSCs alone influenced levels of pRb^(Ser608) in hostcardiomyocytes FIGS. 1E, 1F). However, combined engraftment of hMSCs andhCSCs resulted in major inactivation (˜60% of the cardiomyocytes ininfarct and border zones) of pRb as evidenced by pRb^(Ser608+) (FIGS.1E, 1F). Because pRbSer608 expression confers proliferative activity inadult newt cardiomyocytes, the rates of mitosis were analyzed incardiomyocytes between groups. Engraftment of hCSCs or hMSCs alone didnot increase the rates of cardiomyocyte proliferation 4 weeks aftertherapy (FIG. 3). However, combined engraftment of hMSCs and hCSCs,increased the number of HP3⁺ cardiomyocytes within the infarcted zone by3-fold compared to the hMSC-treated animals and by 10-fold compared tohCSC and placebo treated groups (p<0.0001) (FIG. 3). In infarct borderzones, this potentiation was of greater magnitude: there was a 6-foldincrease in the numbers of HP3⁺ cardiomyocytes compared to the hMSC andhCSC therapies alone, and a 46-fold increase relative to placebo(p<0.0001) (FIG. 3). Additionally, morphometric analysis illustratedthat the cross-sectional areas of these newly formed cardiomyocytes weresignificantly smaller compared to cardiomyocytes in the placebo treatedgroup (p<0.05), providing evidence that they are transient amplifyingprogeny of host CPCs19 (FIG. 7). The abundance of pRb^(Ser608)correlated significantly with the numbers of cardiomyocytes in mitosis(FIG. 8A), further supporting the conclusion that hMSCs/hCSCsinteractions induce pRb^(Ser608) inactivation and the subsequentregulation of cardiomyocyte cell-cycle activity.

MSCs/CSCs Interactions Yield pRbSer608+/ARF(−) Transient AmplifyingCardiomyocytes

There were fewer mitotic cardiomyocytes compared to pRb^(Ser608+)cardiomyocytes, indicating that, compared to the newt, pRb^(Ser608)inactivation was not sufficient to trigger massive cell cycle re-entry.To address the possibility that ARF suppresses adult pRb^(Ser608)cardiac myocytes from progressing to mitosis, ARF myocardial expressionwas analyzed. It was found that ARF was expressed in the majority ofcardiomyocytes, including the pRb^(Ser608+) cardiomyocytes, of allgroups (FIG. 3, FIGS. 9A-9H). However, in swine treated with thecombination of hMSCs and hCSCs, ARF was significantly repressed in ˜20%of pRb^(Ser608+) cardiomyocytes (FIG. 3). Additionally, althoughtransient inactivation of ARF is necessary for progression from G phaseto mitosis, animals treated with the combination of hMSCs and hCSCscontained mitotically dividing cardiomyocytes with an HP3⁺/pRb^(Ser608+)but ARF-negative phenotype, providing evidence that the regeneration ofmature cardiomyocytes with broadened proliferative potentials within theinjured porcine heart (FIG. 3, FIG. 10).

Importantly, the abundance of pRb^(Ser608+)/ARF-negative cellscorrelated with the degree of cardiomyocyte mitosis ((p=0.003); FIG.8B). Thus, these findings support that hMSCs/hCSCs interactions arecapable of inactivation both pRb and ARF facilitating transientamplifying cell and cardiomyocyte completion of the cell cycle.

pRb^(Ser608) and ARF Correlate with Scar Regression

Lastly, to determine whether pRb^(Ser608) activity reflects myocardialregeneration at the whole organ level, the prediction that levels ofpRb^(Ser608+) cardiomyocytes and CPCs correlated with cardiac MRI-basedchanges in scar size was tested. Indeed, the levels of pRb^(Ser608+)Gata4⁺ CPCs within the infarct zone correlated with the reduction inmyocardial scar size in response to cell therapy (FIG. 4). In contrast,the levels of pRb^(Ser608+) cardiomyocytes did not correlate withmyocardial scar reduction (FIG. 4). However, pRb^(Ser608+)/ARF-negativemyocytes within the infarct and the border zones did correlate with the% of scar size reduction (FIG. 4). Thus, these findings substantiatethat, mammalian cardiac myocytes have the capacity for regenerativecompetence.

Discussion

Retinoblastoma is a tumor suppressor widely expressed in adult mammaliantissues and in stem cell niches that regulates cell-cycle activity(Walkley C R, et al. Cell 2007 Jun. 15; 129(6):1081-95; Calo E, eta al.Nature 2010 Aug. 26; 466(7310):1110-4; Burke J R, et al. Genes Dev 2012Jun. 1; 26(11):1156-66). In invertebrates and in regenerating tissues,pRb is inactivated alone and in combination with a parallel pathway thatalso suppresses cell-cycle activity, the ARF (Conkrite K, et al. J ClinInvest 2012 May 1; 122(5):1726-33; Bettencourt-Dias M, et al. J Cell Sci2003 Oct. 1; 116(Pt 19):4001-9; Pajcini K V, et al. Cell Stem Cell 2010Aug. 6; 7(2):198-213). Given the growing awareness that successfulcardiac regeneration in response to cell therapy involves endogenousregenerative pathways, the hypothesis was tested that cell therapy withappropriate cells leads to combined inactivation of pRb and ARF in hostprecursor, transient amplifying, and fully formed myocytes. Together,the data presented here support a key role for this dual inactivation inadult mammalian cardiac tissues. Indeed the presence of precursors withdual inactivation predicted the degree of myocardial recovery post stemcell injection. These effects were mediated by a coordinated action of astromal cell and a c-kit⁺ progenitor cell. These findings have importantimplications for the elucidation of the pathways governing tissueregeneration in adult mammals as well as for the design andimplementation of optimal cell-based therapeutic strategies.

Our studies in a pig model of myocardial infarction have shown thattransplantation of a combination of bone marrow-derived mesenchymal stemcells (MSCs) and cKit⁺ cardiac progenitors (CSCs) results in asignificant reduction in scar size and improvement in heart functioncompared to animals not receiving the stem cell therapy. Theseimprovements are accompanied by, and correlate to, a significantincrease in the detection frequency of a population of small,mononucleated cardiac myocytes in mitosis. Immunophenotypic analysiswith confocal microscopy revealed that, compared to the non-mitoticallydividing cardiomyocytes, these small cardiomyocytes in mitosis exhibithyperphosphorylation in Rb at Serine 608 (Rb^(Ser608+)), and lackexpression of ARF. In contrast, non-dividing cardiomyocytes exhibitstrong expression of ARF, and an underphosphorylated state of Rb. Wealso detected a large pool of Rb^(ser608+) cardiomyocytes within andaround the infarct scar zone which were not in mitosis. Importantly,these non-dividing Rb^(Ser608+) cardiomyocytes strongly expressed ARF.Furthermore, animals receiving the stem cell therapy present asignificant increase in the detection frequency of Gata⁺ myocardialprogenitors which are also Rb^(Ser608+). Collectively, these datasuggest that Rb activity underlies the mechanisms of cardiomyogenesis inmammals and that the cardiogenic activity of Rb might be regulated bythe cyclin-dependent kinase inhibitor, ARF.

Example 2: Rb Knock-Down Enhances Cardiomyocyte Differentiation

To further explore the role of Rb in cardiomyogenis in in vitro models,human embryonic (hESCs) and induced-pluripotent (hIPSCs) stem cells,were used. Protocols were established to guide their in vitrodifferentiation into spontaneously beating human cardiomyocytes. In apreliminary set of experiments, gene-expression analysis revealed thatinduction of cardiogenic program overlaps with a sharp induction in theexpression of both Rb and ARF (FIG. 11). These findings are in completeaccordance with the hypothesis and in vivo studies in pigs (disclosed inExample 1) which show that Rb activity underlies the mechanisms ofcardiomyogenesis in mammals and that the cardiogenic activity of Rbmight be regulated by the cyclin-dependent kinase inhibitor, ARF. Togain further insights on the role of Rb in cardiogenesis, transgenicline of hESCs were obtained, in which an shRNA against Rb was stablytransduced using a tetracycline-inducible GFP-expressing lentiviralvector (pSLIK). This system allowed to conditionally knockdown Rb inhESCs by the addition of doxycycline in the culture medium, and observethe fate of the affected cell populations by the expression of GFP.Preliminary results demonstrated that addition of doxycycline wasaccompanied by strong expression of GFP (FIG. 12A, B) as measured byfluorescent microscopy, and a ˜50% reduction in the expression levels ofRb compared to control.

To test the role of Rb on differentiation of myocardial progenitors tohuman cardiomyocytes, hESCs were subjected to cardiac differentiationprotocol. Notably, under this protocol, development of spontaneouslycontracting embryoid bodies were seen within 7 days after embryoid bodyformation (EB-day 7). Accordingly, addition of doxocycline was initiatedfrom EB-day 5 to EB-day 8, in order to knockout RB1 in cardiacprogenitors prior to their differentiation into beating cardiomyocytes.Quantification of beating embryoid bodies illustrated that, although thenumbers of beating EBs on day 8 were similar between the RB1-knockdownand control groups (FIG. 13A), by EB-day 10, the percentage of beatingembryoid bodies in the RB1-knockdown groups were 44.6±3.8% compared to19.0±3.3% in the control group (p=0.0002, one-way ANOVA).Gene-expression analysis of Rb revealed a reduced expression Rb indox-treated EBs, when compared to the control group (FIG. 13C).Importantly, fluorescence microscopy illustrated that 100% of thebeating EBs in the RB1-knockdown group were GFP⁺, illustrating that RB1shRNA was strongly expressed during their differentiation intocardiomyocytes (FIG. 13B). Further, gene-expression analysis of day 10EBs revealed that Rb knockdown significantly enhanced thetranscriptional activities of the cardiac lineage-specific markersGata4, Isl1 and cardiac troponin I (TnnI) when compared to control (FIG.14), supporting the role of Rb as a regulator of human cardiomyocytegenesis. Importantly, these changes were accompanied by a significantincrease in the expression of CDK4, CDK6, E2F2 and E2F3 (FIG. 15)suggesting that Rb operated through a CDK4/6 and E2F-related pathways.In addition, enhanced expression of the CDK inhibitors CDKN1b(p21^(kip1)) CDKN1c (p57^(kip2)) CDKN2a (ARF), CDKN2b (p15^(Ink4b)),CDKN2c (p18^(Ink4c)) and CDKN3 were also recorded (FIG. 16).Furthermore, although knockdown of Rb triggered a significant increasein the transcriptional activity of p107 and p130 (FIG. 16), theiractivity was not sufficient to suppress cardiogenesis, supporting thehypothesis that differentiation of human cardiac progenitors tocardiomyocytes is regulated by Rb and not p107 and p130.

What is claimed is:
 1. A method of treating a heart disease in a subjectin need thereof comprising administering a pharmaceutical compositioncomprising a therapeutically effective amount of isolated composition ofcardiac progenitor cells, wherein the composition of cardiac progenitorcells comprises cardiac progenitor cells that are phosphorylatedretinoblastoma protein positive.
 2. The method of claim 1, wherein thephosphorylated retinoblastoma protein is hyperphosphorylated Rb.
 3. Themethod of claim 1, wherein the phosphorylated retinoblastoma isphosphorylated at position Ser 608 of Rb.
 4. The method of claim 1,wherein the composition of cardiac progenitor cells comprises cardiacprogenitor cells that are positive for Gata4 (Gata4⁺).
 5. The method ofclaim 1, wherein the composition of cardiac progenitor cells comprisescardiac progenitor cells that are negative for ARF (ARF⁻).
 6. The methodof claim 1, wherein the composition of cardiac progenitor cellscomprises cardiac progenitor cells that are positive for Gata4 (Gata4⁺)and negative for ARF (ARF⁻).
 7. The method of claim 1, wherein thecomposition of cardiac progenitor cells comprises cardiac progenitorcells that are phosphorylated retinoblastoma protein positive, positivefor Gata4 (Gata4⁺), and negative for ARF (ARF⁻).
 8. The method of claim1, wherein the heart disease is cardiovascular disease, cardiomyopathy,myocardial stunning, peripheral vascular disease, intermittentclaudication, tachycardia, ischemia-reperfusion, myocardial infarction,acute renal failure, stroke, hypotension, embolism, or thromboembolism(blood clot).
 9. The method of claim 1, wherein the heart disease iscardiomyopathy.
 10. The method of claim 1, wherein the composition ofcardiac progenitor cells comprises cardiac progenitor cells that areN-cadherin^(pos), connexin-43^(pos), Isl1^(pos), Wt1^(pos), CDK2^(pos),CDK4^(pos), CDK6^(pos), E2F^(pos), phospho-p107^(pos),phospho-p130^(pos), CCNAP^(pos), CCND1^(pos), CCND2^(pos),CCND3^(pos)CCNE^(pos), c-kit^(pos), CD3^(neg), CD14^(neg), CD68^(neg),Nkx2.5^(pos), MITF^(pos), MEF2c^(pos), or any combination thereof. 11.The method of claim 1, wherein the pharmaceutical composition furthercomprises mesenchymal stem cells.
 12. The method of claim 1, wherein thepharmaceutical composition is suitable for parenteral administration.13. The method of claim 1, wherein the pharmaceutical composition issuitable for intravenous administration.
 14. The method of claim 1,wherein the heart disease is myocardial infarction.
 15. The method ofclaim 1, wherein the heart disease is hypotension.